c 


THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 


PRESENTED  BY 

PROF.  CHARLES  A.  KOFOID  AND 

MRS.  PRUDENCE  W.  KOFOID 


DISEASES 


OF  THE 


NARES,  LARYNX 

AND 

TRACHEA 


IN 


CHILDHOOD. 


THOMAS  N1CH0L,  M.  D.,  LL.  D.,  S.  C.  L, 

Member  of  the  Colleges  of  Physicians  and  Surgeons   of  Ontario  and 

Quebec ;  Member  of  the  American  Institute  of  Homoeopathy, 

and  Corresponding  Member  of  the  Homoeopathic 

Medical  Society  of  Pennsylvania. 


NEW    YORK: 
A.  L.  Chatterton  Publishing  Company. 

1885. 


COPYRIGHT,   1885, 
BY 

A.  L.  CHATTERTON  PUBLISHING  CO. 


MARTIN  A  NIPER, 

.  t  Binder 'A 

218  Fii.ton  St.,  Bkooklyn. 


. 


INSCRIBED    TO 

ALEXANDER  THOMPSON  BULL,  M.  U., 

OF    BUFFALO, 

Whom  the  author  is  proud  to  claim  as  his  preceptor  in    "the  art 
almost   Divine." 


iwasnaw 


PREFACE. 

The  essays  composing  this  volume  are  the  fruits  of  thirty 
years  of  study  and  experience.  Some  of  them  appeared  in 
the  America)!  Observer  many  years  ago,  and. now,  encouraged 
by  professional  friends,  they  appear  in  book  form,  revised 
and  enlarged.  The  pathology  of  each  morbid  state,  has  been 
dwelt  on  at  great  length,  simply  because  a  correct  under- 
standing of  the  natural  history  of  disease  is  indispensable 
to  the  scientific  physician  of  any  school.  The  homoeopathic 
treatment  is  fuller  and  more  minute  than  in  any  similar 
work,  and  the  author's  extensive  experience  enables  him  to 
speak  with  some  little  authority  on  this  point.  Should  this 
volume  be  favorably  received,  it  will  be  followed  by  another 
on  the  Diseases  of  the  Bronchi  and  Lungs. 

140  Mansfield  Street,  Montreal,  March,  1885. 


Table  of  Contents. 


CHAPTER  I. 

PAGE. 

Acute  coyza,       ........        25 

Definition,  25  ;  etiology,  26  ;  symptomatology,  27  ;  prognosis, 
29  :  therapeutics,  29  ;  general  treatment,  37  ;  aphorisms,  38. 

CHAPTER  II. 

Purulent  coryza,  .......        39 

Definition,  39  ;  etiology,  41  ;  symptomatology,  42  ;  progress.  44  ; 
thermometry,  44  ;  pathological  anatomy,  44  ;  diagnosis,  45  ; 
prognosis,  46 ;  therapeutics,  47  ;  aphorisms,  50. 

CHAPTER  III. 
Chronic  coryza,  .  .  .  .  .  .  .51 

Definition,  51  ;  varieties,  51  ;  nature,  51  ;  symptomatology,  52; 
progress,  53  ;  thermometry.,  53  ;  diagnosis,  53  ;  prognosis,  54  ; 
general  treatment,  54  ;  therapeutics,  54  ;  aphorisms,  63. 

CHAPTER  IV. 
Spasm  of  the  glottis,  ......        64 

Definition,  64  ;  nature,  65  ;  etiology,  67  ;  symptomatology,  77  : 
pathological  anatomy,  .82  ;  diagnosis,  S4 ;  prognosis,  S5  ;  mode 
of  death,  87  ;  therapeutics.  87  ;  general  treatment,  no:  chlor- 
oform, in  ;  tracheotomy,  ill  ;  aphorisms,  114. 

CHAPTER  V. 

Acute  catarrhal  laryngitis,  .  .  .  .  .116 
Definition,  116;  varieties,  117;  history,  117;  etiology,  11S  ; 
symptomatology,  11S  ;  thermometry,  121  ;  pathological  anat- 
omy, 122  ;  diagnosis,  123  ;  prognosis,  124  ;  general  man- 
agement, 125  ;  prevention,  125  ;  therapeutics,  127  ;  aphor- 
isms, 131. 

CHAPTER  VI. 

Acute  ^edematous  laryngitis,  .....       132 

Definition,  132  ;  etiology,  133  ;  varieties,  133  ;  history,  134  ; 
symptomatology,  136  ;  progress,  137  ;  duration,  137  ;  scald 
throat,  138  ;  pathological  anatomy,  13S  ;  diagnosis,  140  ;  prog- 
nosis, 142  ;  therapeutics,  143  ;  scarification,  149  ;  tracheot- 
omy, 150  ;  aphorisms,  152. 


viii  CONTEN  IS. 

CH  \riKK  VII. 

iMODIC  CROUP,  .......         154 

Definition,    155;  frequency,  i?7  ;  etiology,  157;  symptomatol- 
.  [59 ;  auscultation,   rl  osis,  163;  prognosis,  163; 

therapeutics,    [63  ;  general    management,    16S  ;  prevention, 
aphorisms,  17". 

en  \riTk  VIII. 

-Ml  MBRANi  H  -    CROl   I'.  .  .  .  .  .171 

Definition,  17;,.  history,  174;  etiology.  177;  recurrence,  181  ; 
heredity,  182  ;  contagion,  1S5  ;  symptomatology,  190  ;  mech- 
anism, 196  ;  progress,  199  ;  thermometry,  200  ;  auscultation, 
2P2  ;  laryngoscopy,  203  ;  essential  nature,  204  ;  pathological 
anatomy,  205  ;  diagnosis,  210  ;  prognosis,  212  ;  general  man- 
agement, 214  ;  tracheotomy,  215  ;  therapeutics,  218  ;  aphor- 
isms, 233. 

CHAPTER  IX. 
DlPH  I  HER1  1  l'     1  ROUP,        .......        235 

Definition,  235  ;  history,  236  ;  symptomatology,  244  ;  progress, 
246  ;  pathological  anatomy,  249  ;  identity  or  non-identity  with 
pseudo-membranous  croup,  252  ;  prognosis,  266  ;  tracheot- 
omy, 26S  ;  general  management,  274  ;  therapeutics,  2S5  ; 
aphorisms,  286. 

CHAPTER  X. 

SCAR]  A  I  I\  'I     CROt  I'.  ......  .        286 

Definition,  2SS  ;  symptomatology,  289;  pathological  anatomy, 
290  ;  diagnosis,  291  ;  prognosis,  292  ;  therapeutics,  292  ; 
prevention,  292  ;  aphorisms,  293. 

CHAPTER  XI. 
Tracheitis,  ........      294 

Definition,  295  ;  etiology.  296  ;  thermometry,  299  ;  pathologi- 
cal anatomy,  299  ;  diagnosis,  300  ;  prognosis,  300  ;  general 
management,  300  ;  therapeutics,  301  ;  aphorisms,  302. 


CHAPTER  I. 


Acute   Cory z a 


Coryza  is  one  of  the  most  annoying  of  the  affections  of 
infancy  and  childhood,  and,  though  in  general  mild,  it  is  not 
destitute  of  danger  to  very  young  infants.  It  may  be  defined 
to  be  a  catarrhal  inflammation  of  the  Schneiderian  membrane 
— the  mucous  membrane  lining  the  nasal  cavity — for  "  the 
nose  is  the  classical  seat  of  catarrh."  All  the  ancient  physi- 
cians, including  the  Sage  of  Cos  himself,  believed  that  the 
secretion  of  the  nose  flowed  down  from  the  brain,  a  doctrine 
that  was  only  exploded  in  1660,  when  Schneider,  of  Witten- 
berg, whose  name  is  still  given  to  the  mucous  membrane  of 
the  nose,  showed  its  erroneous  nature.  The  phenomena  of 
Coryza  are  of  great  interest  to  the  physician  from  the  fact 
that  the  diseased  pa»"ts  may  be  seen,  and  the  changes  which 
take  place  in  the  Schneiderian  membrane  are  no  doubt  strictly 
analogous  to  those  which  take  place  in  the  mucous  mem- 
brane lining  the  larynx  and  bronchial  tubes. 

Generally  speaking,  the  mucous  membrane  of  the  respira- 
tory organs  is  extremely  sensitive  in  childhood,  but  it  is  a 
curious  fact  to  which  the  attention  of  the  profession  was  first 
called  by  Professor  Jorg,  of  Leipsic,  that  this  extreme  sensi- 
bility does  not  exist  during  the  first  seven  or  eight  weeks  of 


j(,  ACUTE    CORYZA. 

life.  "The  exposure  of  an  infant  two  or  three  weeks  old  to 
a  low  temperature  or  to  a  vitiated  air  will  be  followed  by 
disturbance  of  the  function  of  the  liver,  and  the  occurrence 
of  jaundice  ;  or,  perhaps,  the  muscular  power  may  be  so  far 
depressed  as  to  render  the  child  incapable  of  taking  a  full 
inspiration,  so  that  its  lungs  collapse,  and  it  dies  from  disor- 
der of  the  respiratory  organs,  but  without  the  cough  and 
bronchitic  symptoms,  which  would  not  fail,  if  it  were  a  little 
older,  to  announce  the  irritation  of  the  mucous  membrane 
of  the  air  tube.  Why  this  is  so  I  do  not  know,  but  I  sup- 
pose it  to  be  the  result  of  the  generally  feeble  vitality  which 
renders  the  lining  of  the  bronchia  less  susceptible ;  just  as 
that  of  the  intestine  also  seems  to  be  at  the  same  period, 
since,  while  constipation  is  frequent,  diarrhoea  is  compara- 
tively rare  during  the  first  two  months  of  life."  (West.) 
But  it  would  appear  that  the  nasal  mucous  membrane  does 
not  possess  this  happy  insensibility,  and  during  the  first  two 
months  coryza  is  frequently  annoying  and  at  times  dan- 
gerous. 

Coryza  generally  results  from  the  action  of  cold,  from 
damp  air  of  a  low  temperature,  exposure  to  the  weather, 
especially  at  the  change  of  seasons,  and  especially  is  it 
caused  by  insufficient  dress.  Many  people  dress  their  little 
ones  as  if  they  possessed  adamantine  constitutions,  and  it  is 
not  uncommon  to  see  a  strong  man  warmly  muffled  up,  walk- 
ing with  a  shivering  urchin  very  insufficiently  clad.  In 
infants  it  is  sometimes  caused  from  the  extremities  being 
chilled  by  the  urine  if  the  changing  of  the  napkin  is  neg- 
lected. In  some  instances,  infants  are  attacked  with  coryza 
so  soon  after  birth  that  it  would  almost  seem  that  they  had 
been  born  with  it.  These  cases  are  no  doubt  caused  by  the 
sudden  transition  from  the  warm  temperature  of  intra  uterine 
life  to  the  trying  and  changeable  circumstances  of  ordinary 
existence. 

Coryza  may  also  be  produced  by  exposure  to  the  heat  of  a 
strong  fire  or  of  the  sun,  and  a  "summer  cold  "  is  proverbi- 
ally difficult  of  cure. 


ACUTE    CORYZA.  2.J 

Acute  coryza  is  a  prominent  symptom  of  the  first  stages 
of  several  infectious  diseases,  particularly  of  measles.  As  a 
general  rule,  acute  coryza  extends  downwards,  though  some- 
times the  reverse  holds  good,  and  it  may  follow  pharyngitis 
or  laryngitis,  and  it  is  an  occasional  termination  of  bron- 
chitis. Acute  coryza  is  sporadic  and  epidemic  but  never 
contagious,  though  many  hold  that  it  may  be  communicated 
by  using  the  same  handkerchief,  thus  bringing  the  nostrils 
into  direct  contact  with  the  morbid  secretion.  But  so  far, 
no  one  has  yet  succeeded  in  demonstrating  the  contagious- 
ness of  acute  coryza  by  experiment,  for  Friedrich  uniformly 
failed  when  he  inoculated  his  own  Schneiderian  membrane 
with  the  secretion  of  people  suffering  from  all  stages  of  the 
disease.  Children  of  all  ages  are  liable  to  this  affection,  but 
it  is  most  frequent  in  nurslings  and  children  during  the  first 
years  of  life.  As  the  infant  grows  older  the  liability  to 
coryza  increases,  and  the  larynx  and  bronchial  tubes  are 
more  likely  to  be  involved.  Female  infants  are  more  liable 
to  the  disease  than  males,  from  the  fact  that  they  are  gener- 
ally more  feeble,  and  the  foolish  pride  of  dress  causes  them 
to  be  less  efficiently  clad. 

The  first  symptom  of  acute  coryza  is  sneezing,  with  dry- 
ness of  the  nostrils,  causing  a  kind  of  snuffling  respiration 
from  which  its  common  name  of  "snuffles"  is  derived,  but, 
as  Dr.  Churchill  points  out,  not  every  young  infant  which 
sneezes  often  has  taken  cold,  for  "  the  impression  of  light 
upon  the  branches  of  the  fifth  pair  of  nerves  distributed  to 
the  eyes  naturally  gives  rise  to  sneezing."  Accompanying 
the  sneezing  is  a  fullness  and  swelling  with  tickling  and  itch- 
ing of  the  nostrils.  In  a  short  time  there  is  a  copious  secre- 
tion of  watery  fluid,  colorless  and  transparent  and  of  a  saltish 
taste,  which  flows  in  a  stream  from  the  nostrils  and  which 
sometimes  causes  excoriation  of  the  upper  lip  and  the  sides 
of  the  nose.  This  irritating  quality  seems  to  be  due  to 
ammonia,  and  in  spite  of  the  salt  taste  very  little  sodium 
chloride  is  present.  As  the  disease  advances  the  secretion 
becomes    purulent    or   muco-purulent.      The    Schneiderian 


28  \CUTE    CORYZA. 

membrane  is  now  vascular,  tender  and  irritable,  and  the 
sense  of  smell  is  almost  wholly  suppressed.  The  child 
breathes  by  its  mouth,  and  respiration  is  attended  by  a  snuf- 
fling or  rather  snoring  noise,  which  is  almost  pathognomonic. 
When  this  swelling  of  the  mucous  membrane  is  very  consid- 
able  the  child  is  almost  unable  to  suck,  for  the  nostrils  being 
closed,  it  is  impossible  to  use  the  mouth  for  suction  and 
respiration  at  one  and  the  same  time ;  of  this  any  one  may 
convince  himself  by  trying  to  suck  while  compressing  the 
nostrils  tightly.  The  little  one  attemps  to  nurse,  but  in  a 
few  seconds  the  face  darkens  and  it  desists,  crying  and 
lamenting.  Impelled  by  hunger,  it  again  attempts  to  nurse, 
and  after  repeated  efforts,  it  finally  becomes  exhausted  with 
hunger,  fatigue  and  suffering.  The  difficulty  of  swallowing 
is  greatly  increased  if  the  catarrhal  irritation  should  extend 
to  the  fauces. 

The  catarrhal  irritation  extends  along  the  lachrymal  pas- 
sage causing  the  eyes  to  become  red  and  watery,  and  later 
the  disease  extends  to  the  frontal  sinuses,  causing  a  dull 
aching  pain  in  the  forehead  which  the  child  tries  to  alleviate 
by  rubbing  the  forehead  with  its  hand  or  boring  the  head 
into  the  pillow.  As  might  be  expected,  there  is  a  good  deal 
of  fever,  the  pulse  is  quickened,  the  skin  is  hot  and  some 
thirst  is  present.  The  senses  of  taste  and  hearing  are  less 
acute  than  in  health,  though  they  rarely  suffer  to  the  same 
extent  as  the  sense  of  smell. 

Such  an  attack  is  at  its  height  in  three  or  four  days,  after 
which  it  declines.  The  difficulty  of  breathing  ceases,  the 
discharge  becomes  thicker,  and  the  danger  now  is  that,  if  im- 
perfectly cured,  the  disease  may  become  chronic.  For  some 
time  after  recovery  the  patient  is  liable  to  relapses  on  very 
slight  exposure  to  exciting  causes. 

The  nasal  mucous  membrane  is  of  a  uniform  red  color,  for 
the  capillaries  are  surcharged  with  blood — at  times  it  is  red- 
dened only  in  points.  Soon  all  the  subjacent  tissues  are 
infiltrated,  and  the  mucous  membrane  becomes  soft  and 
swollen,  and  a  slight  swelling  is  sufficient  to  fill  the  nasal 
cavity,  which  is  very  small  in  young  children. 


ATI  TE    CORYZA.  2Q 

Coryza  is  a  comparatively  trifling  disease  in  children  of 
four  or  five  years  of  age,  but  it  is  a  serious  disorder  in  nurs- 
ing infants.  Dr.  J.  T.  Meigs  considers  it  "  a  serious  and  even 
dangerous  disease,"  while  Bouchut  styles  it  "  a  very  danger- 
ous disease  in  children  at  the  breast.'  Dr.  George  B.  Wood 
points  out  that  on  attempting  to  take  the  breast,  children 
sometimes  become  black  in  the  face  from  suspended  respira- 
tion, and  that  they  are  said  occasionally  to  be  thrown  into 
convulsions  by  the  same  cause.  Both  Wood  and  West  admit 
that  fatal  cases  occur  from  the  difficulty  of  breathing  and 
sacking.  Fraenkel  remarks  that  a  fatal  termination  is  ex- 
tremely rare,  and  only  takes  place  in  nurslings  owing  to  the 
disturbances  of  respiration  and  nutrition  incident  to  closure 
of  the  nose.  "  While  acute  nasal  catarrh  is  a  complaint  as 
common  as  it  is  harmless,  it  sometimes  proves  dangerous  to 
infants  at  the  breast,  because  the  obstruction  of  their  nasal 
passages,  which  are  at  all  times  narrow,  makes  it  difficult  for 
them  to  suck.  If  we  do  not  feed  with  a  spoon  in  such  cases, 
life  itself  may  be  endangered  in  ill  nourished  or  feeble  chil- 
dren."    (Felix  von  Niemeyer.) 

Coryza  responds  readily  to  homeoepathic  treatment,  es- 
pecially when  it  is  aided  by  rational  adjutants. 

Aconite  is,  according  to  Doctor  Hayward,  the  best  reme- 
dy for  the  incipient  stage  of  coryza.  As  a  general  rule,  it  is 
indicated  by  the  symptoms  during  the  first  twenty-four 
hours,  and,  if  promptly  and  persistently  given,  it  often  obvi- 
ates the  necessity  for  any  other  remedy.  The  indications 
are  creeping  chills,  following  exposure  to  dry,  cold  air  or  to 
a  draught,  and  these  chills  are  followed  by  burning  heat, 
especially  on  the  head  and  face  ;  spasmodic  sneezing  and 
discharge  of  a  thin,  watery  fluid  from  the  nostrils,  with  great 
thirst,  especially  towards  evening.  A  short,  dry  cough  from 
irritation  of  the  larynx  is  often  present  and  profuse  lachryma- 
tion  is  an  almost  invariable  accompaniment. 

The  child  is  fearful  and  afraid  during  the  day,  and  at 
night  the  sleep  is  restless  and  dream-haunted  ;  the  patient 
feels  better  in   a  cool  room.     A  very  small  powder  of  the 


30  -\i  i   ri:    CORYZA. 

sixth  or  eighth  decimal  trituration  should  be  given,  dry  on 
the  tongue,  every  hour  or  every  two  hours.  Hering  does 
not  recommend  aconite  for  the  primary  disease,  but  "when 
the  catarrh  has  been  suppressed  and  headache  is  the  result, 
give  aconite.'' 

Camphor  is  another  useful  remedy  in  the  incipient  stage  ; 
indeed  it  is  of  little  or  no  use  unless  it  is  given  as  soon  as 
the  morbid  state  appears.  Dr.  Hughes  considers  it  more 
generally  useful  than  Aconite.  "A  few  doses  of  it  rapi  !ly 
dissipate  that  chilly  feeling  which  with  most  persons  is  the 
precursor  of  a  cold  in  the  head."  Camphor,  then,  is  indi- 
cated by  the  chilly  or  cold  stage  when  the  malady  is  still  in 
its  incipiency  ;  shivering  or  coldness  of  the  skin  which  at 
the  same  time  is  dry,  and  along  with  this  there  is  heaviness, 
weariness  and  general  malaise.  Camphor  is  too  much 
neglected,  and  this  neglect  probably  arises  from  the  fact 
that  few  practitioners  carry  the  remedy  in  their  pocket- 
cases.  Place  one  drop  of  the  Rubini  tincture  on  a  small 
piece  of  pure  white  sugar  and  give  one-tenth  of  this  every 
twenty  or  thirty  minutes.  I  have  seen  decided  good  follow 
the  repeated  olfaction  of  the  Rubini  tincture.  If  the 
morbid  state  progresses,  Camphor  should  be  discontinued 
and  some  one  of  the  under-mentioned  remedies  given. 

Nux  vomica  has  been  much  recommended  for  coryza, 
though  Dr.  Ilempel  remarks,  "  we  have  never  been  so 
fortunate  as  to  effect  anything  great  with  Nux  in  a  catarrh 
affection  of  any  kind."  On  the  other  hand,  Dr.  Hughes 
says,  "  for  the  stuffy  cold  I  think  (herein  again  coinciding 
with  Jahr)  that  Nux  vomica  is  specific  ;  "  and  Dr.  Ruddock 
agrees  with  the  recommendation.  Jousset  recommends  this 
remedy  in  the  incipient,  dry  stage  of  fluent  coryza,  and  says 
that  by  giving  a  dose  of  the  third  dilution  every  hour  he 
has  often  arrested  the  malady  by  the  end  of  its  first  day. 
Here  I  must  range  myself  on  the  side  of  my  old  friend, 
time-honour'd  Ilempel,  for  I  have  rarely  seen  much  good 
from  Nux  vomica  in  catarrhal  affections.  Hering  recom- 
mends Nux  for  the  same  symptoms  as  Arsenicum  when  the 


ACUTE    CORVZA.  3 1 

latter  causes  no  improvement  in  twelve  hours,  or  when  the 
catarrh  is  fluid  during  the  day  and  dry  at  night.  Nux 
vomica  is  usually  given  during  the  first  stage  when  there  is 
dryness  or  obstruction  of  the  nose,  with  heaviness  in  the 
forehead  and  impatient  mood ;  the  mouth  is  dry  and 
parched,  without  much  thirst  ;  tightness  of  the  chest ; 
constipation.  Chills  and  heat  alternate  in  the  evening,  and 
great  heat  of  the  face  and  head  is  present.  Nux  vomica  has 
stoppage  of  the  nose  especially  out  doors  but  fluent  indoors, 
while  the  Pulsatilla  coryza  is  fluent  outdoors  and  stoppep 
indoors.  This  remedy  acts  best  in  small  doses  of  the  30th 
dilution,  given  in  the  evening. 

Mercurius  is  frequently  given  after  Aconite,  and  is  perhaps 
the  most  frequently  indicated  remedy  in  coryza.  Hughes 
styles  it  ''  the  established  remedy,"  though  personally  he 
has  a  preference  for  Euphrasia,  and  Bsehr  says  that  it  is  "  a 
distinguished  remedy  which  will  scarcely  be  surpassed  by 
any  other."  The  symptoms  are  frequent  sneezing,  with 
soreness  and  redness  of  the  nose,  and  constant  watery  dis- 
charge which  gradually  becomes  purulent.  The  smell  from 
the  nostrils  is  often  offensive,  and  the  lips  are  swollen  and 
excoriated.  The  eyelids  are  irritated  with  constant  shed- 
ding of  tears,  and  this  irritation  may  extend  to  the  air- 
passages,  causing  cough  with  mucous  rales.  There  is  alter- 
nate heat  and  shivering,  the  heat  predominating  over  the 
chills,  with  profuse  perspiration  which  affords  no  relief. 
The  patient  feels  uncomfortable  in  a  warm  room,  yet  cannot, 
bear  the  cold.  Hering  thinks  that  Mercurius  is  especially 
serviceable  for  children,  and  Ruddock  says  that  it  is  often 
useful  in  alternation  with  Nux  vomica,  a  recommendation  in 
which  I  cannot  concur  for  the  simple  reason  that  we  have 
no  proving  of  the  two  remedies  in  alternation,  and  if  we  had, 
the  results  would  be  worthless.  Concerning  the  preparation 
of  Mercurius  to  be  administered,  Teste  lays  down  "  that 
corrosive  sublimate  is  indicated  in  an  immense  majority  of 
the  cases  which  have  been  considered  until  now  as  belong- 
ing to  the  sphere  of  soluble  mercury,  provided  that,  with  a 


$2  ACUTE    CORYZA. 

few  exceptions,  corrosive  sublimate  is  given  exclusively  in 
the  diseases  of  males,  and  soluble  mercury  in  the  diseases  of 
females."  Experience  has  amply  confirmed  this  statement, 
and  yet  Merc.  sol.  acts  well  with  children  of  either  sex. 
.Merc.  corr.  deserves  the  preference  in  coryza  when  the 
sneezing  is  excessive,  and  Mercury  sol.  when  there  is  dull 
headache  with  great  accumulation  of  mucus  in  the  posterior 
nares.  Mercurius  acts  well  in  all  preparations,  but  I  prefer 
small  doses  of  the  twelfth  decimal  trituration,  dry  on  the 
tongue. 

Ilepar  is  of  great  service  when  the  air  passages  are  chiefly 
affected,  when  the  cough  is  loose  and  croupy,  with  rattling 
in  the  chest,  pain  in  the  upper  part  of  the  windpipe  while 
coughing,  with  hoarseness.  The  nose  is  often  red  and 
swollen,  with  scabby  formations  in  the  nostrils  and  loss  of 
smell.  Hepar  is  especially  indicated  when  the  catarrh  is 
renewed  by  every  breath  of  wind,  or  when  it  affects  only 
one  nostril  and  the  headache  is  increased  by  every  move- 
ment. This  remedy  is  useful  in  most  cases  of  ordinary 
catarrh  after  partial  relief  from  Mercurius.  Hering  advises 
it  when  the  symptoms  have  been  better  and  became  worse 
again,  and  Hayward  uses  it  "  to  bring  up  the  tone  of  the 
parts  to  its  natural  degree."  I  have  had  the  best  results 
from  the  12th  decimal  trituration. 

Arsenicum  is  of  great  service  when  the  nostrils  are  stuffed 
up,  with  copious  discharge  of  thin  watery  mucus,  burning  of 
the  nose  both  externally  and  internally,  with  soreness  of  the 
adjacent  parts.  The  nose  is  often  swollen  and  there  is 
frequent  sneezing.  The  discharge  is  burning  and  corrosive, 
excoriating  the  upper  lip  and  neighboring  parts,  and  I  have 
often  verified  the  indication  given  by  Jahr:  "excellent  if 
the, nose  is  obstructed  in  spite  of  the  copious  dischirge." 
There  is  foul  smell  from  the  nose  and  occasionally  nosebleed 
is  present.  The  patient  is  cold  and  chilly  and  the  chills  are 
intermixed  with  flushes  of  heat  ;  general  debility  and  pros- 
tration are  almost  invariably  present.  Hering  remarks  that 
this  remedy  is  indicated  "  when  there  is  not    much    fever, 


ACUTE    CORYZA.  33 

heat  or  thirst  ;  "  but  I  think,  with  Baehr,  that  it  is  indicated 
"  when  the  constitutional  symptoms  are  very  prominent  and 
intense."  The  sufferings  are  relieved  by  warmth  and  exer- 
cise, and  exposure  does  not  aggravate  the  disease.  The 
patient  is  thirsty,  but  drinks  little  at  a  time.  The  remedy 
is  especially  appropriate  when  the  child  has  taken  cold  after 
a  bath.  As  to  dose,  Bayes  thinks  that  from  the  3d  to  30th 
will  prove  very  serviceable,  but  after  a  long  experience  I 
find  that  I  have  had  better  results  from  the  orthodox  Hahn- 
emann ian  30th  than  from  any  other. 

Chamomilla,  though  greatly  neglected,  is  really  one  of  the 
leading  remedies  for  acute  coryza  in  infants  and  young 
children,  and  Laurie  remarks  that  "  in  the  treatment  of 
children  this  medicine  is  generally  preferable  to  Nux  vomica 
in  arresting  the  attacks."  Chamomilla  is  indicated  when 
the  coryza  has  arisen  from  suppressed  perspiration,  when  a 
good  deal  of  fever  is  present,  one  cheek  being  red  and  the 
other  pale,  chilliness  and  thirst  are  present,  the  temper  is 
fretful  and  irritable,  and  the  child  wants  to  be  carried  all  the 
time.  The  nostrils  are  often  ulcerated  and  the  lips  chapped, 
and  the  discharge  from  the  nose  is  copious  and  acrid.  A 
hoarse  cough  is  frequently  present  with  rattling  of  mucus  in 
the  bronchial  tubes,  and  this  cough  is  worse  at  night,  even 
during  sleep.  Chamomilla  is  doubly  indicated  if  catarrh 
should  make  its  appearance  during  dentition.  Twelve  years 
ago  I  wrote  that  Chamomilla  should  never  be  given  lower 
than  the  twelfth  dilution  ;  I  am  now  of  the  opinion  that  I 
should  have  written  'thirtieth'  instead  of '  twelfth.' 

Belladonna  is  indicated  by  a  dry,  barking,  spasmodic 
cough,  coming  on  in  paroxysms,  apparently  caused  by 
titillation  in  the  air  passages,  aggravated  at  night.  Pain  and 
heat  in  the  head,  eyes  and  nose  are  present,  a  throbbing, 
bursting  headache,  with  flushed  face  and  glistening  eyes. 
The  tonsils  are  swollen  and  red,  with  difficulty  of  swallow- 
ing and  sensation  of  constriction  in  the  throat.  The  breath- 
ing is  short,  anxious  and  hurried ;  the  pain  in  the  head 
causes  the  child  to  bore  its  head  into  the  pillow  or  to  rub  it 


34  U   '  TE    CORY/A. 

with  the  hands.  The  fever  is  quite  high,  with  alternate 
chilliness  and  heat.  The  coryza  is  fluent,  but  the  remedy  is 
indicated  not  so  much  by  the  coryza  as  by  the  other 
symptoms.  Baehr  recommends  Belladonna  if  the  tonsils  are 
inflamed,  and  Jahr  and  Bering  agree  in  recommending  it  if 
1  lepar  should  prove  insufficient.  I  have  usually  given  from 
the  6th  to  the  12th  dilutions,  but  have  seen  excellent  results 
from  the  30th. 

Allium  Cepa  is  indicated  when  catarrh  is  epidemic  with 
much  sneezing  and  running  of  the  nose,  which  is  inflamed 
and  sore  down  to  the  upper  lip  ;  the  nasal  discharge  is 
burning  and  excoriating.  The  eyes  smart  and  burn,  with 
profuse  discharge  of  bland  water;  tingling  and  itching  of 
the  left  nostril  with  violent  sneezing.  A  laryngeal  cough  is 
also  present,  which  increases  towards  evening.  The  catarrh 
commences  mostly  on  the  left  side  and  moves  to  the  right ; 
it  is  worse  at  night  and  in  a  room,  better  in  the  open  air 
and  in  the  cold.  Dr.  Hering,  in  his  lectures,  was  in  the 
habit  of  insisting  that  Allium  Cepa  was  the  very  closest 
simillimum  to  coryza,  and  he  considered  that  it  occupied  a 
middle  place  between  Aconite  and  Ipecacuenha.  I  have 
had  the  best  results  from  the  12th  centesimal  dilution  in 
repeated  doses. 

Ruphrasia  has  been  too  much  neglected  in  this  disease, 
though  it  is  more  used  at  the  present  time  than  it  was  twen- 
ty years  ago.  "  It  acts  upon  the  upper  portion  of  the  res- 
piratory mucous  membrane,  i.  e.,  upon  the  conjunctival 
and  nasal  portions,  only  just  reaching  the  larynx.  It  develops 
in  this  region  a  catarrhal  inflammation,  generally  charac- 
terized by  profuse  secretion.  Hence  it  takes  a  first  place 
among  the  remedies  for  fluent  coryza  when  this  is  a  local 
affection,  and  not  a  symptom  of  general  influenza,  in  which 
latter  case  Arsenic  is  preferable.  The  involvement  of  the 
conjunctiva  in  the  catarrh  is  a  special  indication  for  Euphra- 
sia, and  sometimes  the  secretion  from  the  eyes  is  acrid, 
while  that  from  the  nares  is  bland,  the  opposite  condition 
obtaining  with  Arsenic."  (Hughes).     The  Euphrasia  coryza 


ACUTE    CORVZA.  35 

is  violent  and  profuse,  excessive  discharge  of  white  mucus 
from  the  nostrils,  and  this  mucus,  though  generally  bland,  is 
sometimes  acrid.  The  eyes  are  red  and  sore  and  the  mar- 
gins of  the  eyelids  are  occasionally  ulcerated,  with  copious 
flow  of  tears.  There  is  cough,  but  only  during  the  daytime, 
and  the  entire  disease  is  worse  at  night  on  lying  down. 
Laurie  recommends  it  to  be  given  twelve  hours  after  the 
last  dose  of  Mercurius,  if,  after  other  symptoms  having 
yielded,  the  flow  of  tears  and  cold  in  the  head  remain  un- 
mitigated, and  I  have  often  acted  on  this  recommendation 
with  excellent  results.  Hughes  says  that  "  small  doses  of 
the  mother  tincture,  as  recommended  by  Hahnemann  him- 
self, appears  to  answer  all  purposes  excellently  well."  Rud- 
dock recommends  from  the  mother-tincture  to  the  3d  deci- 
mal dilution.  Bayes  says  "  the  disease  is  readily  cured  by 
Euphrasia  6  or  12."  My  own  experience  has  been  made 
with  the  3d  decimal  dilution. 

Pulsatilla  is  frequently  suitable  after  Chamomilla,  and, 
according  to  Bashr,  "  it  may  afford  more  relief  than  any  other 
remedy  when  infants  at  the  breast  are  attacked  with 
catarrh,  which,  even  if  it  runs  its  ordinary  course,  becomes  a 
source  of  distress  because  it  prevents  them  from  nursing." 
It  is  indicated  by  a  flow  of  thick,  yellowish,  fetid  mucus, 
swelling  of  the  nose  with  ulceration  of  the  nostrils,  frequent 
sneezing  and  roughness  of  the  voice.  The  child  is  chilly  in 
the  evening  and  has  whining  moods,  with  loss  of  smell  and 
appetite  ;  feels  better  in  the  fresh  air,  worse  in  the  warm 
room.  Jahr  remarks  that  "  Pulsatilla  is  appropriate  if,  after 
the  mucus  begins  to  assume  a  thicker  consistence,  the  nose 
is  alternately  stopped  and  running ;  this  remedy  is  scarcely 
ever  indicated  as  long  as  the  discharge  is  watery,  but  is  very 
often  better  adapted  to  the  case  than  any  other  medicine  if 
the  nose  continues  to  discharge  for  an  undue  length  of  time 
a  thick  yellow  or  green  mucus,  and  likewise  if  the  nose  is 
only  obstructed  in  the  evening  and  in  the  room,  and  runs 
again  in  the  open  air."  "  When  nasal  catarrh  has  passed 
into    its    third    stage   of  thick  and  bland  discharge,  and  is 


;/>  \.  i    II     CORYZA. 

inclined  to  linger,  Pulsatilla  is  the  medicine  best  calculated 
to  hasten  its  departure,  and  may  be  relied  on  no  less  in 
chronic  coryza  of  simple  character  and  without  constitution- 
al taint.  It  will  cure  even  when  the  flux  is  so  profuse  as  to 
deserve  the  name  of  rhinorrluea,"  and  the  present  writer  has 
succeeded  in  effecting  cures  in  a  number  of  cases  in  which 
the  disease  had  affected  the  frontal  sinuses,  with  very  offen- 
sive discharge.  Like  Chamomilla,  this  remedy  acts  best  in 
the  much-ridiculed  thirtieth  dilution. 

Sambucus  is  suitable  for  new-born  infants;  the  nostrils  are 
obstructed  by  a  thick,  tenacious  mucus ;  the  throat  and 
mouth  are  dry,  and  the  nostrils  seem  to  be  completely  closed, 
yet  no  thirst  is  present.  The  child  has  sudden  startings 
from  sleep  as  if  suffering.  Sambucus  is  the  only  remedy 
mentioned  by  Hempel  for  this  disease  in  children.  Noack 
and  Trinks  recommend  one  drop  of  the  mother-tincture  or 
of  the  1st,  2d  or  3d  dilution  once  or  twice  daily,  and  it  is 
almost  always  given  in  low  dilutions. 

Dulcamara  is  the  most  appropriate  remedy  for  children 
who  are  subject  to  severe  coughs,  or  to  sore  throat  whenever 
they  are  exposed  to  a  damp  atmosphere.  The  patient  feels 
better  when  in  motion  and  worse  during  rest,  and  the  slightest 
exposure  renews  the  obstruction-  of  the  nose.  In  such  cases 
Dulcamara  is  preventive  as  well  as  curative,  and  it  acts  best 
in  the  lower  dilutions. 

Other  remedies  are  Carbo  veg.  for  fluent  coryza  with 
hoarseness  and  rawness  of  the  chest  ;  Arum  Triph.  for  acrid 
fluent  cory/.a  excoriating  the  nostrils  and  adjacent  parts  ; 
Cyclamen,  the  Pulsatilla  of  chronic  diseases,  according  to 
Hering,  for  frequent  sneezing  with  profuse  discharge ;  Am- 
nion, carb.  for  dry  coryza  with  stoppage  of  the  nose  ;  Sang. 
Canad.  for  fluent  coryza  with  cough  and  diarrhoea;  Ipec. 
when  there  is  difficulty  in  breathing,  "  give  a  couple  of  times  " 
1  I  lering) ;  Bryonia  for  hard  cough  with  soreness  of  the  chest, 
also  for  difficulty  of  breathing  if  Ipec.  does  not  relieve 
(Hering). 


ACUTE    CORYZA.  37 

Hippocrates  recommended  that  the  nose  should  be  greased 
with  the  view  of  alleviating  the  difficulty  of  breathing,  and 
this  simple  expedient  is  just  as  effective  now  as  it  was  two 
thousand  years  ago.  Where  the  nostrils  are  dry  and  ob- 
structed, injections  of  glycerine  and  tepid  water  afford  relief. 
"  During  the  first  day  or  two  steaming  the  head  and  face  will 
afford  great  relief,  especially  if  a  few  drops  of  Aconitum  be 
added  to  the  water ;  and  whilst  giving  the  mercurius  inter- 
nally the  same  medicine  may  be  used  as  spray,  warm  (5  grs. 
of  the  1st  trituration  to  8  oz.  of  water);  the  patient  should  be 
kept  to  one  room,  and  the  air  should  be  kept  warm,  65 °,  and 
moist  by  having  steam  continually  escaping  into  it."  (Hay- 
ward.)  "  If  the  nasal  obstruction  is  such  that  it  entirely 
prevents  respiration  and  suction,  the  physician  should  at- 
tempt the  introduction  of  a  small  silver  tube  into  each  nos- 
tril;  it  should  be  flattened,  and  curved  from  before  back- 
wards following  the  course  of  the  floor  of  the  fossae,  and 
afterwards  fixed  under  the  nose  with  the  neighboring  tube. 
These  two  provisionary  canulae  allow  the  passage  of  air,  and 
prevent  the  child  from  dying  at  once,  by  giving  the  disease 
time  to  cure  itself."     (Bouchut.) 

Dr.  Charles  D.  Meigs  directs  a  flannel  cap  to  be  put  upon 
the  child  and  worn  for  two  or  three  days.  The  cap  should 
be  removed  as  soon  as  the  coryza  is  relieved,  as  otherwise 
the  child  is  apt  to  become  so  accustomed  to  it  as  to  take 
fresh  cold  when  it  is  removed.  Dr.  Ruddock  thinks  that 
infants  should  be  taught  to  breathe  through  the  nostrils, 
especially  during  sleep,  but  I  fear  that  is  "  easier  said  than 
done." 

Of  all  the  auxiliary  measures  that  have  been  recommended, 
I  have  found  the  "thirst  cure"  the  most  efficient.  It  was 
first  suggested  by  Dr.  C.  J.  B.  Williams  in  the  Cyclopedia  of 
Practical  Medicine,  and  is  a  most  powerful  means  of  cure. 
"  It  is  the  acrimony  of  this  discharge  (from  the  pituitary 
membrane)  which  reacts  on  the  membrane  and  keeps  up  the 
inflammation  and  its  accompanying  disagreeable  circum- 
stances.    On    this    circumstance  depends   the    efficacy  of  a 


j8  VCUTE    CORYZA. 

measure  directly  opposed  to  that  just  noticed,  but  to  the 
success  of  which  we  can  bear  decided  testimony — we  mean 
it  total  abstinence  from  liquids.  This  method  of  cure  oper- 
ates by  diminishing  the  mass  of  fluid  in  the  body  to  such  a 
degree  that  it  will  no  longer  supply  the  diseased  secretion. 
The  coryza  begins  to  be  dried  up  about  twelve  hours  after 
leaving  off  liquids;  from  which  time  the  flowing  to  the  eyes 
becomes  gelatinous,  and  between  the  thirtieth  and  thirty- 
sixth  hour  ceases  altogether.  The  whole  period  of  absti- 
nence needs  scarcely  ever  to  exceed  forty-eight  hours."  The 
thirst  cure  is,  of  course,  not  suitable  for  nursing  children,  but 
for  those  who  are  past  that  stage  I  know  no  better  aid  to 
the  homeopathic  remedies. 

Dr.  Constantine  Hering  in  his  lectures  was  much  in  the 
habit  of  dwelling  upon  the  connection  between  the  use  of 
salt  and  sugar  on  the  one  hand  and  coryza  and  catarrhal 
affections  on  the  other.  "If  a  patient  is  subject  to  very 
frequent  recurrence  of  catarrhs  which  are  very  difficult  of 
cure,  it  will  often  be  found  that  he  eats  too  much  salt.  In 
this  case  he  should  be  as  moderate  in  the  use  of  salt  as  pos- 
sible, and  smell  now  and  then  sweet  spirits  of  nitre."  And 
again.  "  Never  suppress  a  cold  either  by  cold  or  drugs,  it  is 
always  a  purifying  process.  Nobody  takes  cold  who  has  not 
other  impurities  in  his  system.  One  is  much  more  liable  to 
catch  cold  after  eating  or  drinking  sharp,  superfluous  or  indi- 
gestible things.  Many  children  will  not  get  rid  of  a  cold  as 
long- as  they  indulge  in  too  much  sugar,  syrup  and  other 
sweets." 

Aphorisms. 

i.  Snuffling  of  the  nose,  with  its  attendant  difficulty  in 
breathing,  at  once  .calls  our  attention  to  coryza. 

2.  Coryza  is  not  a  dangerous  disease,  save  in  the  case  of 
feeble  infants,  for  fatal  cases  undonbtedly  occur  from  the  dif- 
ficulty of  breathing  and  sucking. 

3.  Aconite  and  Camphor  are  the  leading  remedies  for  the 
early  stages,  and   Mercurius  and  Arsenicum  for  the  more 


PURULENT    CORYZA.  39 

advanced,  but  Euphrasia,  Chamomilla  and  Allium  Cepa  have 
hitherto  been  too  much  neglected. 

4.  The  thirst  cure  is  the  most  effective  of  the  accessary- 
means  of  cure,  and,  according  to  Constantine  Hering.  the 
immediate  use  of  salt  is  one  of  the  chief  predisposing  causes, 
while  the  immediate  use  of  su^ar  hinders  the  cure. 


CHAPTER  II. 


Purulent  Coryza. 


Purulent  coryza,  called  by  Underwood  coryza  maligna  or 
morbid  snuffles,  is  an  inflammation  of  the  mucous  membrane 
of  the  nose  in  infants  which,  still  being  acute,  differs  from 
simple  coryza  in  the  much  graver  character  of  its  symptoms. 
Its  distinguishing  feature  is  the  presence  of  a  purulent  secre- 
tion accompanying  an  inflammation  of  a  more  or  less  malig- 
nant nature  ;  Dr.  Fraenkel,  who  has  given  us  an  excellent 
essay  on  this  disease,  thinks  that  it  would  be  etymologically 
more  correct  to  call  it  a  pyorrhoea  than  a  blennorrhoea.  This 
morbid  state  rarely  occurs  alone,  being  often  associated  with 
angina,  conjunctivitis  or  otitis,  and  in  my  own  practice  I 
have  seen  purulent  coryza  as  a  sequel  of  scarlet  fever,  diph- 
theria and  measles.  In  these  cases  a  pseudo-membranous 
exudation  is  present  which  is  frequently  not  to  be  distin- 
guished from  a  diphtheritic  membrane.  In  illustration  of 
this  variety  of  coryza  I  quote  the  following  instructive  case, 
occurring  as  a  complication  of  scarlatina,  from  Dr.  Charles 
West :  "  In  this  instance,  a  little  boy,  six  months  old,  was 
brought  to  me  on  the  25th  of  October,  1842.  His  health 
had  been  good  until  the  20th,  when  he  became  hoarse  ;  on 


40  PURULENT    CORYZA. 

the  22d  this  hoarseness  had  much  increased,  and  he  became 
unable  to  suck,  since  which  time  he  had  continued  to  grow 
worse.  When  I  saw  him  his  skin  was  warm,  face  rather 
flushed,  eyes  watering,  and  a  thick,  ropy  musus  obstructed 
his  nostrils.  He  cried  with  a  suppressed  but  squeaking  voice, 
and  breathed  with  a  peculiar  wheezy  noise,  though  air  enter- 
ed the  chest  unattended  with  any  rale.  The  child  was  una- 
ble to  suck,  and  even  when  he  drank  from  a  cup  the  fluid 
often  returned  through  his  nose.  The  inside  of  the  mouth 
was  very  red,  and  the  tonsils  and  soft  palate  were  especially 
so.  The  mouth  was  full  of  an  extremely  tenacious  mucus, 
which  it  was  necessary  from  time  to  time  to  take  out  with 
the  hand.  A  lotion  was  injected  up  the  nostrils,  composed 
of  ~  j  of  alum  to  3  ij  of  water,  with  great  relief  to  the  child, 
the  secretion  from  the  nares  becoming  more  decidedly  puri- 
form,  but  less  adhesive  ;  and  the  child  became  able  to  suck 
a  little.  On  the  28th,  however,  the  child's  powers  seemed 
much  depressed  ;  it  sucked  eagerly,  for  the  secretion  from 
the  nose  had  become  almost  watery,  but  it  swallowed  with 
much  difficulty.  A  layer  of  false  membrane  of  a  yellowish- 
white  color  had  now  appeared  on  the  soft  palate  and  back  of 
the  hard  palate,  and  on  the  tonsils.  A  lotion  of  three  grains 
of  nitrate  of  silver  to  an  ounce  of  water  was  applied  to  the 
back  of  the  throat,  and  a  mixture  of  the  extract  of  bark  with 
ammonia  was  given  every  six  hours.  On  the  first  of  Novem- 
ber the  ehild  was  better,  could  both  swallow  and  suck  well, 
and  the  false  membrane  had  entirely  disappeared  from  the 
mouth ;  but  the  palate  was  still  red,  and  presented  some 
broad  superficial  patches  of  ulceration.  The  subsequent 
recovery  was  tardy,  but  the  immediate  danger  was  over,  and 
no  relapse  occurred."  No  one  can  doubt  but  that  at  the 
present  day  this  case  would  be  pronounced  diphtheritic  by 
well-read  and  experienced  practitioners  of  all  schools,  and 
probably  Dr.  West  himself  would  now  be  of  that  opinion. 
Denman  describes  an  epidemic  of  this  disease  under  the 
name  of  coryza  maligna,  and  he  states  that  in  connection 
with   the  coryza  there  was  a  general  fulness  of  the  throat 


PURULENT    CORYZA.  41 

and  neck  externally;  that  the  tonsils  were  tumefied,  and  of 
a  dark-red  color,  with  ash-colored  specks,  and  in  some  cases, 
with  extensive  ulcerations  ;  and  that  some  of  the  children 
swallowed  with  difficulty.  Meigs  and  Pepper,  in  comment- 
ing on  Denman's  remarks,  say,  "there  can  therefore  be  little 
doubt  but  that  in  reality  these  were  cases  of  nasal  diphthe- 
tia,"  but  most  observers  would  omit  the  adjective  nasal  and 
simply  call  them  diphtheritic. 

Purulent  coryza  chiefly  occurs  on  the  Continent  of  Europe, 
especially  in  the  Foundling  Hospitals;  less  frequently  is  it 
found  in  Great  Britain,  while  on  this  continent  the  disease  is 
so  seldom  seen  that  many  practitioners  have  never  seen  a 
case.  On  the  whole,  then,  purulent  coryza  is  a  somewhat 
rare  disease,  so  much  so  that  Rilliet  and  Barthez,  the  leading 
French  writers  on  the  diseases  of  children,  do  not  even  men- 
tion it.  It  affects  both  sexes  with  like  frequency,  and  is 
usually  seen  in  the  newly-born,  and  hardly  ever  in  children 
over  twelve  months. 

The  causes  of  simple  acute  coryza,  exposure  to  a  damp  or 
cold  atmosphere  or  neglect  in  changing  the  infant's  clothing, 
have  but  little  influence  in  causing  the  much  more  serious 
purulent  coryza,  though  unquestionably  a  certain  proportion 
of  cases  arise  from  accidental  aggravations  of  the  milder  dis- 
ease, and  I  attended  a  case  in  which  this  result  was  produced 
by  exposure  of  a  child  suffering  from  the  simple  form  of 
coryza  to  the  heat  of  a  strong  fire.  But  the  most  influential 
factor  in  the  etiology  of  this  disease  is  undoubtedly  the  infec- 
tion of  the  mucous  membrane  of  the  child's  nose  with  the 
secretions  of  the  maternal  vagina  during  birth,  so  that  the 
disease  is  strictly  analogous  to  ophthalmia  neonatorum.  This 
view  of  the  chief  cause  of  the  disease  is  confirmed  by  the 
facts  that  it  almost  invariably  appears  during  the  first  days 
of  life  ;  that  it  rarely  attacks  children  whose  mothers  are  not 
suffering  from  leucorrhoea  or  some  similar  malady:  and,  last- 
ly, that  it  is  most  frequent  in  little  ones  who,  from  various 
causes,  have  been  long  detained  in  the  maternal  passages 
during  birth.     Then  again,  in  the  great  majority  of  cases,  all 


42  PURULENT    CORYZA. 

other  causes  of  the  disease,  save  infection  by  maternal  secre- 
tions, can  be  excluded  with  almost  absolute  certainty.  It  is 
worthy  of  remark  that  ophthalmia  neonatorum  is  much  more 
frequent  than  purulent  coryza  caused  by  the  maternal  secre- 
tions, and  this  comparative  immunity  of  the  nasal  passages 
probably  arises  from  the  movements  of  the  eyelids  favoring 
the  entrance  of  the  infecting  matter  in  the  one  case,  while  in 
the  other  the  ciliated  epithelium  of  the  nasal  mucous  mem- 
brane probably  acts  as  a  protector  against  the  materies 
morbi. 

As  soon,  then,  as  the  child  is  born,  or  at  least  a  very  brief 
period  after  birth,  a  watery,  bloody  discharge  from  the  nose, 
accompanied  by  sneezing,  announces  the  onset  of  the  disease. 
Sometimes  stoppage  of  the  nose  precedes  the  discharge,  but 
as  a  general  rule  the  latter,  which  is  the  pathognomonic 
symptom  of  the  disease,  makes  its  appearance  first.  This 
discharge  is  usually  yellow  in  color,  odorless,  at  first  glutin- 
ous, but  soon  it  becomes  thicker  and  purulent  with  a  peculiar 
smell,  which,  however,  differs  from  the  fetid  odor  of  chronic 
coryza.  At  times  it  resembles  the  "laudable  pus"  of  the 
older  surgeons,  at  times  it  has  the  color  of  prune  juice  from 
an  admixture  with  blood,  but,  as  a  general  rule,  it  is  puru- 
lent, rarely  mucous.  Later  it  is  thickish,  rather  solid  in  con- 
sistence, especially  when  the  cause  of  the  disease  is  infection 
from  the  maternal  secretions.  A  thin,  ichorous  discharge, 
containing  at  a  later  date  small  granular  particles — really  the 
detritus  of  the  pseudo-membrane — indicates  the  presence  of 
false  membrane,  which,  on  examination  by  a  strong  light,  is 
seen  covering  the  nasal  mucous  membrane  with  a  uniform 
yellowish-white  coating.  Soon  the  alae  nasi  and  adjoining 
parts  are  inflamed  and  swollen,  and  the  red  and  shining  skin 
is  really  the  seat  of  an  erysipelatous  inflammation.  The 
upper  lip  is  red  and  swollen,  and,  at  a  later  stage,  it  is  exco- 
riated by  the  secretions.  I  have  never  noticed  "  the  curious 
purple  streak  on  the  margin  of  the  eyelids"  which  Denman 
considered  to  be  pathognomic  ;  and  in  many  cases  there  is  a 
fulness  and  swelling  about  the  throat  and  neck  externally, 


PURULENT    CORYZA.  43 

resembling  the  well-known  enlargement  of  diphtheria. 

The  swelling  of  the  nasal  mucous  membrane  is  much 
greater  than  in  the  simple  coryza,  and,  as  a  result,  the  breath- 
ing is  difficult,  nasal  and  snoring.  Young  infants  breathe 
almost  exclusively  by  the  nostrils,  and  when  these  are  plugged 
by  the  inspissated  secretion  of  this  disease,  they  seem  to 
be  quite  unable  to  keep  the  mouth  open  in  order  to  compen- 
sate for  the  closure.  When  the  mouth  is  kept  open  it, 
together  with  the  tongue  and  throat,  becomes  dry  and  stiff, 
and  the  infant  makes  such  violent  efforts  to  breathe  as  to 
conduce  greatly  to  a  fatal  termination  to  the  disease.  When 
the  nostrils  are  closed  the  child,  unable  to  breathe  and  suck 
at  the  same  time,  refuses  the  breast,  or  only  nurses  at  con- 
siderable intervals  and  with  great  difficulty.  Cough  is  rarely 
present,  except  in  those  cases  in  which  the  disease  has 
extended  to  the  fauces ;  bleeding  from  the  nose  sometimes 
occurs  in  the  pseudo-membranous  form  of  the  disease. 

The  general  appearance  of  the  child,  from  the  very  begin- 
ning, indicates  a  serious  malady,  quite  different  from  even 
severe  cases  of  simple  acute  coryza,  for  in  addition  to  the 
intense  inflammation  of  the  entire  nasal  mucous  membrane, 
there  is  great  constitutional  debility  present  in  almost  all 
cases.  The  violent  attacks  of  dyspncea  are,  of  course,  the 
result  of  the  closure  of  the  nostrils,  and  the  restlessness,  de- 
pression and  emaciation  are  the  expression  of  the  constitu- 
tional disease.  The  skin  becomes  dry  and  harsh,  and  as  the 
emaciation  progresses  it  becomes  wrinkled,  and  low  fever  and 
somnolence  are  frequently  seen  in  advanced  stages.  I  have 
never  met  with  the  disorder  of  the  bowels,  with  thick,  pasty 
stools  of  a  green  or  blue  color,  of  which  Fleetwood  Churchill 
speaks. 

In  favorable  cases  the  inflammation  with  its  accompanying 
discharge  diminishes,  the  swelling  of  the  nasal  mucous  mem- 
brane— which  carries  with  it  so  much  of  danger — subsides, 
breathing  becomes  quite  easy,  and  the  child  soon  enters  upon 
convalescence.  Of  course,  as  soon  as  the  nasal  passages  per- 
mit free  respiration  the  act  of  sucking  becomes  easy,  and 


44  PURULENT    CORYZA. 

with  this  the  debility  and  emaciation  soon  pass  away.  But 
all  cases  have  not  this  favorable  termination,  for  the  little 
one  may  perish  from  inanition  caused  by  pain,  fatigue  and 
insufficient  nourishment,  and  the  fatal  result  is  ushered  in  by 
drowsiness  which  soon  deepens  into  coma.  Death,  in  these 
cases,  is  often  caused  by  effusion  on  the  brain,  and,  indeed, 
severe  brain  symptoms  are  frequently  associated  with  puru- 
lent coryza. 

Violent  cases  of  this  disease  may  prove  fatal  in  three  or 
four  days,  and  milder  cases  may  run  on  for  a  week  or  ten 
days  before  amendment  takes  place,  but  even  then  final  re- 
covery only  comes  after  careful  treatment  of  the  destructive 
processes  in  cartilage  and  bone  so  apt  to  follow  severe  ulcer- 
ative inflammation.  The  duration  of  the  disease  depends 
greatly  upon  the  age  of  the  patient,  for  in  very  young  infants 
the  fatal  termination  is  always  nearer  at  hand  and  always 
more  threatening  than  when  the  patient  is  at  least  a  year  old. 

In  severe  cases  of  purulent  coryza,  the  thermometer  shows 
a  temperature  of  ioi°  to  1040,  and  such  high  temperatures 
add  very  greatly  to  the  danger.  Still,  in  one  malignant  case 
which  I  attendedjn  the  year  i860,  the  temperature  was  quite 
low  throughout,  and  a  moderate  temperature  is  no  guarantee 
for  a  favorable  termination,  especially  if  the  disease  tends  to 
assume  the  malignant  form. 

Dr.  Denman,  the  celebrated  accoucheur,  met  with  an  un- 
usual number  of  cases  of  purulent  coryza,  encountering  eight 
cases  in  eight  months,  of  which  six  died.  One  of  the  bodies 
was  opened  by  John  Hunter  and  Sir  Everard  Home,  who 
detected  nothing  save  that  the  nasal  mucous  membrane  was 
of  a  dark-red  color,  and  its  bloodvessels  more  turgid  than 
usual.  Later  observers  note  that  the  mucous  membrane  is 
softened  as  well  as  thickened  throughout  the  entire  extent 
of  the  nasal  fossae,  and  that  the  membrane  is  thickly  coated 
with  pus  or  a  thick,  tenacious  mucus.  On  removing  this 
mucus  exuded  blood  is  seen,  mostly  in  minute  points,  which 
were  thrown  out  in  the  course  of  the  disease.  In  other  cases 
patches   of    the    pseudo-membranous    exudation    are    found 


PURULENT    CORZA.  45 

scattered  over  the  surface  of  the  nasal  mucous  membrane, 
and  this  exudation  is  not  necessarily  diphtheritic.  In  other 
cases  again  the  swollen  mucous  membrane,  of  a  vivid  red 
hue,  is  covered  throughout  its  entire  extent  with  a  closely- 
adherent  pseudo-membrane  which  extends  over  the  entire 
interior  of  the  nares,  and  these  are  the  cases  which  it  is 
almost  impossible  to  distinguish  from  diphtheria.  On  re- 
moving the  pseudo-membrane  the  subjacent  mucous  mem- 
brane is  found  to  be  softened  and  extremely  ulcerated. 
Bouchut  remarks  that  very  commonly  the  false  membranes 
are  not  situated  in  the  interior  of  the  nasal  fossse,  but  only 
at  the  orifice  of  the  nostrils.  Purulent  coryza  can  hardly  be 
confounded  with  simple  acute  coryza,  for  the  violent  inflam- 
mation with  purulent  discharge  of  the  first-named  is  entirely 
different  from  the  catarrhal  inflammation  with  mucous  dis- 
charge of  the  other.  The  differential  diagnosis  between 
purulent  coryza  and  diphtheria  is  much  more  difficult,  and 
in  the  advanced  stages  of  the  disease  it  mainly  rests  on  the 
presence  or  absence  of  the  characteristic  diphtheritic  blood- 
poisoning.  If  a  false  membrane  is  distinctly  visible  in  the 
nasal  passages,  or  if  the  nasal  discharge  is  loaded  with  minute 
fragments  of  false  membrane,  and  if  this  is  followed  by  the 
well-known  symptoms  which  mark  the  constitutional  infec- 
tion of  diphtheria,  there  can  be  no  room  for  doubt,  and  the 
disease  is  diphtheria  beyond  a- doubt.  But  when  a  pseudo- 
membrane  lines  the  nasal  passages  without  constitutional 
symptoms  following,  it  is  likely  that  the  disease  is  not  diph- 
theria, for  not  all  false  membranes  are  diphtheritic,  and  most 
experienced  practitioners  have  met  with  cases  of  pseudo- 
diphtheria  which  present  a  most  wonderful  resemblance  to 
the  genuine  disease.  Again,  isolated  patches  are  likely  to 
be  non-diphtheritic,  while  a  continuous  coating  of  false  mem- 
brane is  almost  certainly  diphtheritic.  Abscess  of  the  nose 
has  some  resemblance  to  purulent  coryza,  but  abscess  rarely 
appears  on  both  sides  of  the  nose,  while  purulent  coryza,  as 
a  very  general  thing,  affects  both  sides  with  like  virulence. 
Then  the  course  of  the  diseases  differs  much,  for  in  nasal 


46  It   KULENT    CORYZA, 

abscess  the  one-sided  inflammation  is,  after  a  few  days,  re- 
lieved by  a  discharge  of  pus  which  brings  welcome  repose  to 
the  patient,  while  in  purulent  coryza  the  virulent  inflamma- 
tion is  accompanied  by  purulent  discharge  almost  from  the 
beginning.  Purulent  coryza  has  been  confounded  with  croup, 
though  it  is  difficult  to  understand  how  any  one  could  make 
the  mistake,  for  the  whistling  inspiration  and  sudden  dysp- 
tii  i  a  which  follow  the  closure  of  the  nasal  passages  are  wholly 
unlike  croup,  and  the  application  of  the  stethoscope  to  the 
larynx,  which  should  never  be  omitted  in  croup  and,  indeed, 
all  laryngeal  diseases,  soon  makes  the  case  clear.  Purulent 
coryza  may  possibly  be  confused  with  syphilitic  coryza,  but 
the  history  of  each  case  must  be  carefully  investigated,  the 
entire  course  of  the  disease  is  different  and  the  characteristic 
eruptions  soon  clear  up  the  diagnosis.  Later  it  will  be  con- 
firmed by  the  changes  in  the  shape  of  the  central  incisors  of 
the  upper  jaw,  first  clearly  pointed  out  by  Jonathan  Hutch- 
inson. 

Purulent  coryza  is  always  a  serious  disease,  and  the  danger 
in  each  particular  case  depends  much  upon  the  degree  of 
tumefaction  of  the  nasal  mucous  membrane  and  upon  the 
consistence  of  the  secreted  fluids,  for  upon  these  two  factors 
of  the  disease  depend  the  ability  to  breathe  and  to  suck. 
Denman  lost  three-fourths  of  his  cases,  and  Meigs  and  Pep- 
per say  that  "  the  two  cases  of  idiopathic  membranous  coryza 
in  infants  that  came  under  our  observation  both  proved 
fatal,"  while  "the  four  cases  in  older  children  recovered  with- 
out any  difficulty."  A  good  deal  depends  on  the  age  of  the 
patient.  A  feeble,  newly-born  babe  offers  little  or  no  resist- 
ance to  a  severe  attack  of  purulent  coryza,  but  a  stout  little 
one,  of  say  nine  months,  may  get  through  even  a  severe 
attack.  The  pseudo-membranous  form  is  more  dangerous 
than  the  purulent,  for,  as  has  been  already  remarked,  many 
cases  of  the  pseudo-membranous  variety  are  really  diphthe- 
ritic, though  perhaps  an  equal  number  are  strictly  analogous 
to  the  well-known  pseudo-diphtheria. 

The  nasal  secretions  should  be  removed  as  they  collect, 


PURULENT    CORYZA.  47 

♦ 

though  this  would  be  bad  practice  if  a  tightly-adherent 
pseudo-membrane  is  present.  To  soften  the  secretions  a 
very  small  quantity  of  tepid  water  may  be  thrown  into  the 
nares  by  means  of  a  small  syringe,  and  the  passages  may 
then  be  cleansed  with  a  camel's  hair  pencil.  Fraenkel  re- 
marks that  infants  must  not  receive  injections  into  the  nose 
while  lying  down,  as  in  this  position  the  medicated  fluids  are 
very  apt  to  pass  through  the  pharynx  into  the  opening  of 
the  larynx,  producing  severe  spasm  of  the  glottis.  Indeed, 
the  child  should  be  kept  as  much  as  possible  in  an  upright 
posture,  and  the  little  one's  mouth  should  be  kept  open  in 
severe  cases.  When  the  nostrils  are  completely  blocked  the 
child  should  not  be  put  to  the  breast,  but  the  maternal  milk 
should  be  given  from  a  spoon.  It  is  in  this  disease  rather 
than  in  simple  acute  coryza  that  the  nasal  tubes  of  Bouchut, 
mentioned  in  the  preceding  chapter,  are  useful.  Tubes  of 
soft  rubber  would  be  preferable  to  silver  ones,  though  the 
latter  would  suit  best  if  the  nasal  secretions  are  both  thick 
and  firm. 

I  am  not  aware  of  the  existence  of  any  essay  on  the 
homoeopathic  therapeutics  of  purulent  coryza,  so  I  will  first 
state  my  own  experience  in  the  disease,  and  then  briefly 
indicate  the  remedies  which  will  cure  every  curable  case,  for 
some  cases  of  this  disease  are  incurable  in  that  very  nature. 
My  experience  includes  three  well-marked  cases,  and  these 
were  cured  with  Argentum  nitricum,  Nitric  acid  and  Apis 
mellifica,  each  with  a  single  remedy,  unaided  by  any  adju- 
rant  save  attention  to  cleanliness. 

The  disease  has,  save  in  the  well-marked  pseudo-membran- 
ous form,  an  etiology  which  is  identical  with  that  of  ophthal- 
mia neonatorum.  Now  Argentum  nitricum  is  the  leading 
remedy  for  ophthalmia  neonatorum,  and  Dr.  Hughes  writes 
as  follows:  "I  myself  have  been  so  satisfied  with  even  its 
internal  effects  in  ophthalmia  neonatorum  that  I  have  never 
had  to  resort  to  any  external  measures  beyond  those  needed 
for  cleanliness."  The  experience  of  our  American  oculists  is 
quite  confirmatory  of  its  power  over  such  purulent  inflamma- 


48  Wki  LENT    CORYZA. 

tions  of  the  conjunctiva.  Dr.  Angell  commends  the  remedy 
"  in  affections  of  the  lining  membrane  of  the  lids,  and  of  the 
lachrymal  duct  and  sac,  when  there  is  an  abundant  discharge 
of  pus:"  and  Drs.  Allen  and  Norton  write:  "  The  greatest 
service  that  Argentum  nitricum  performs  is  in  purulent 
ophthalmia.  With  large  experience  in  both  hospital  and 
private  practice,  we  have  not  lost  a  single  eye  from  this  dis- 
ease, and  every  one  has  been  treated  with  internal  remedies, 
most  of  them  with  Argentum  nitricum  of  a  high  potency, 
30th  or  200th.  We  have  witnessed  the  most  intense  chemo- 
sis  with  strangulated  vessels,  most  profuse  purulent  discharge, 
even  the  cornea  beginning  to  get  hazy  and  looking  as  though 
it  would  slough,  subside  rapidly  under  Argentum  nitricum 
internally." 

In  my  first  case  the  child  was  two  months  old,  weak  and 
scrofulous ;  the  mother  had  suffered  for  years  from  a  very 
profuse  leucorrhoea.  Ophthalmia  neonatorum  was  present 
as  well  as  purulent  coryza,  so  that  there  could  be  no  doubt 
as  to  the  etiology  of  the  disease.  The  nose  was  red,  swollen 
and  painful,  especially  over  the  nasal  bones.  Several  pimples 
studded  the  tip  and  neighboring  parts,  and  these  red  and 
angry  pimples  speedily  opened  and  became  small  ulcers. 
The  discharge  was  thick,  yellow  and  blood-streaked,  and 
twice  a  small  hemorrhage  made  its  appearance.  The  child 
was  gloomy  and  sad,  and  the  entire  state  was  worse  after 
midnight  and  also  in  the  morning.  I  gave  Argentum  nitri- 
cum, 1 2th  centesimal  dilution,  and  both  ophthalmia  and 
coryza  were  cured  in  a  fortnight.  No  external  applications 
were  used,  save  abundance  of  tepid  water. 

In  my  second  case  there  was  a  very  strong  suspicion, 
almost  amounting  to  certainty,  of  a  syphilitic  taint.  The 
child  was  four  and  a  half  months  old,  wan  and  withered,  with 
pinched  features  and  skin  drawn  tightly  over  forehead  and 
cheek-bones.  The  mucous  membrane  of  the  nose  was  ulcer- 
ated, with  a  constant  discharge  of  thin,  bloody,  fetid  sanies, 
which  corroded  the  upper  lip.  The  nose  was  of  a  vivid  red, 
and  studded  with  small  yellowish  vesicles  which  broke  and 


PURULENT    CORV/A.  49 

formed  scabs.  As  the  disease  advanced  the  nasal  discharges 
became  thick  and  yellowish,  but  the  streaks  of  blood  disap- 
peared. The  fetid  smell  lingered  to  the  last,  and  we  had 
three  somewhat  profuse  hemorrhages  of  dark  blood,  all  in 
the  night-time,  without  any  special  cause.  The  aversion  to 
the  open  air  was  very  marked,  but  cold  weather  agreed  best 
with  the  child.  I  gave  Nitric  acid,  12th  centesimal  dilution, 
and  the  child  improved  at  once,  though  it  took  three  months 
to  complete  the  cure.     No  other  remedy  was  used. 

My  third  case  was  cured  with  Apis  mellifica,  6th  decimal 
trituration.  It  was  a  well-marked  specimen  of  the  pseudo- 
membranous variety  of  the  disease,  the  nares  being  coated 
with  a  false  membrane  which  yet  was  not  diphtheritic, 
for  it  lacked  the  fetor  which  is  almost  part  and  parcel  of 
diphtheria,  and  no  constitutional  symptoms  accompanied  or 
followed  the  local  disease.  The  nose  was  greatly  swollen, 
red  and  cedematous,  and  so  marked  were  these  external 
symptoms  that  the  relatives  of  the  child  at  first  thought  that 
the  disease  was  erysipelas.  The  mucous  membrane  swelled 
to  such  an  extent  that  the  nose  was  completely  stopped  up 
— even  before  the  appearance  of  the  false  membrane.  The 
inflammatory  action  was  followed  by  the  exudation  of  a  ten- 
acious, gluey  mucus,  which  speedily  became  organized  into 
a  well-marked  false  membrane,  on  removing  which  the  sub- 
jacent mucous  membrane  was  seen  to  be  still  swollen  and 
studded  with  minute  bleeding  points.  The  morbid  action 
extended  to  the  fauces  and  even  threatened  the  larynx,  but 
finally  made  a  good  recovery  in  twelve  days. 

Aconite  would  only  be  of  value  in  purulent  coryza  if  ad- 
ministered very  promptly,  almost  before  the  morbid  state 
had  time  to  develop  itself,  as  it  were  ;  if  given  afterwards 
it  would  cause  the  loss  of  valuable  time.  Belladonna  is  more 
frequently  indicated  than  Aconite,  corresponding  as  it  does 
not  merely  to  the  symptoms  of  the  malady,  but  to  the  path- 
ological state  of  which  the  symptoms  are  the  expression. 
Leading  remedies  are  Mercurius  solubilis,  Hepar  sulphuris, 
Arsenicum    album,  Calcarea    carbonica,  Pulsatilla,   Sulphur, 


50  P0R1  l  i  \  r    i  0RY2A. 

Silicea,  Aurum  muriaticum,  Lachesis  and  Kali  bichromicum, 
the  two  last  mentioned  being  especially  effective  in  the 
pseudo-membranous  form  of  the  disease.  For  the  special 
indications  I  must  refer  the  reader  to  Chapters  I  and  III  of 
this  volume. 

Aphorisms. 

i.  Purulent  coryza  is  a  malignant  inflammation  of  the 
nasal  mucous  membrane  of  infants  characterized  by  a  pro- 
fuse purulent  discharge  and,  at  times,  the  formation  of  false 
membranes  which  yet  are  not  diphtheritic. 

2.  Purulent  coryza  is  chiefly  caused  by  actual  contact  of 
the  infant's  nose  with  morbid  secretions  of  the  maternal  pas- 
sages during  birth,  and  hence  the  disease  is  closely  analogous 
to  ophthalmia  neonatorum. 

3.  Purulent  coryza  is  comparatively  a  rare  disease,  and  the 
mortality,  even  under  the  most  enlightened  treatment,  is 
probably  at  least  one-half  of  the  whole  number  attacked. 

4.  The  pseudo-membranous  form  of  purulent  coryza  is 
distinguished  from  true  diphtheria  of  the  nasal  passages  by 
the  presence  of  constitutional  infection  when  the  disease  is 
diphtheria,  and  also  by  the  fact  that  true  diphtheria  rarely 
attacks  the  nose  alone. 

5.  The  remedies  which  have  proved  successful  in  the 
writer's  hands  are  Argentum  nitricum,  Nitric  acid  and  Apis 
mellifica ;  other  remedies  are  Sulphur,  Mercurius  solubilis, 
Arsenicum  album,  Aurum  muriaticum,  Lachesis  and  Kali 
bichromicum,  the  two  last  named  especially  in  pseudo-mem- 
branous cases. 


CHAPTER  III. 


Chronic  Coryza. 


Chronic  coryza  of  infants  is  comparatively  rare,  but  as  it 
is  exceedingly  difficult  of  cure,  it  is  advisable  to  describe  the 
disease  and  its  treatment  as  fully  as  possible.  This  intract- 
ability arises  from  the  constitutional  taints  which  so  often 
lie  at  the  root  of  the  local  affection,  which,  in  these  cases, 
is  merely  a  manifestation  of  a  constitutional  disease. 

Chronic  coryza  may  be  defined  to  be  the  morbid  state 
which  follows  a  neglected  or  partially  cured  acute  coryza. 
Ulceration  may  be  present,  but  simple,  chronic  inflamma- 
tion of  the  Schneiderian  membrane  is  the  most  common 
pathological  state.  There  are  then  several  varieties  of  chronic 
coryza.  The  most  common  of  these  is  the  simple  form  de- 
pendent on  chronic  inflammation,  and  the  constitutional 
state  here  is  a  low  condition  of  health,  with  mal-nutrition 
and  ansemia.  Next  in  frequency  we  have  the  scrofulous 
variety,  exceedingly  intractable  in  its  nature,  but  still  quite 
amenable  to  homoeopathic  treatment ;  and  the  syphilitic 
variety,  the  most  formidable  of  them  all,  but  which,  as 
Bouchut,  long  ago  pointed  out,  is  cured  more  easily  than 
the  others. 

Chronic  coryza  is  not  nearly  so  common  as  acute  coryza, 
and,  if  all  cases  of  the  last  mentioned  were  carefully  attend- 
ed to,  the  chronic  variety  would  become  still  more  rare.  So 
far  as  I  have  observed,  it  is  not  more  frequent  in  children 
of  one  sex  than  of  the  other.  Some  fault  of  the  general 
health,  some  obscure  constitutional  dyscrasia  is  almost  inva- 
riably the  predisposing  cause  of  chronic  coryza,  and  Fraenkel 
remarks  "  that  acute  rhinitis  may  pass  into  the  subacute  and 


52  I  HRONlC    CORYZA. 

chronic  forms,  and  yet  in  the  vast  majority  of  cases  this  only 
takes  place  in  persons  suffering  under  a  dyscrasia."  In  not  a 
few  cases,  however,  children  not  suffering  from  any  dyscrasia 
may  have  repeated  attacks  of  acute  coryza  which  finally  ter- 
minates in  the  chronic  form. 

The  principal  symptoms  of  chronic  coryza,  as  might  be 
expected,  are  of  a  strictly  local  character.  The  respiration 
is  nasal,  and  embarrassed  even  during  the  day,  and  at  night 
the  obstruction  of  the  nostrils  gives  rise  to  snoring,  or  rather 
hissing  sounds.  The  child's  rest  is  disturbed  by  the  necessity 
of  making  increased  muscular  effort  to  fill  the  chest  with  air, 
and  as  a  result,  the  sleep  is  broken  and  restless.  In  aggra- 
vated cases  the  difficulty  of  breathing  is  so  great  that  the 
blood  becomes  so  thoroughly  carbonized,  that  the  sleep  is 
heavy  and  restless.  On  examining  the  nasal  passages  the 
mucous  membrane  will  be  found  to  be  thickened  and  inject- 
ed. In  the  earlier  stages  it  is  more  highly  vascular  than 
natural,  and  here  and  there  slight  excoriations  are  visible. 
As  the  malady  advances  the  mucous  membrane  becomes 
pale,  bloodless,  and  devoid  of  its  natural  velvet-like  lustre. 
In  many  cases  the  amount  of  .secretion  is  so  much  smaller 
than  in  acute  coryza  that  they  are  spoken  of  as  "  dry  ca- 
tarrhs," while  in  others  the  secretion  is  purulent  and  very 
abundant.  Whether  scant)-  or  copious,  the  secretion  is  so 
viscid  as  to  form  scabs  and  crusts,  or  even  small  lumps  of 
inspissated  mucus,  and  this  combined  with  the  thickened 
state  of  the  mucous  membrane  causes  a  true  stenosis  of  the 
nostrils.  These  crusts  are  moist  and  greenish  in  the  earlier 
stages,  and  dry  and  blackish  in  the  more  advanced  phases 
of  the  disease,  and  if  they  contain  blood  they  are  dark  red- 
dish in  color  and  friable  in  texture.  Very  little  causes  the 
child's  nose  to  bleed,  and  these  frequent  hemorrhages  often 
cause  the  physician  to  be  consulted.  As  the  disease  ad- 
vances the  voice  changes  and  becomes  markedly  nasal.  In 
chronic  coryza  we  do  not  find  the  prickly  itching  in  the 
nostrils,  the  sneezing  or  the  frontal  headache  that  are  so 
prominent    in    acute  coryza,  though  in  some  instances  the 


CHRONIC    CORYZA.  53 

child  would  seem  to  suffer  from  frontal  headache,  judging 
from  the  manner  it  rubs  its  forehead  against  the  nurse's 
shoulder.  The  decomposition  of  the  secretion  gives  rise  to 
a  more  or  less  intense  smell  from  the  nostrils  and  even  from 
the  mouth,  a  peculiar  odor  given  off  with  the  expired  air,  and 
when  this  symptom  is  present,  the  disease  is  called  ozcaia. 

As  the  disease  advances,  the  general  appearance  of  the 
patient  gives  evidence  of  greatly  impaired  health.  The 
face  is  pale,  the  complexion  is  dusky,  the  features  lose  their 
lively  expression,  and  all  the  movements  of  the  child  show 
languor  and  listlessness.  The  sleep  is  unrefreshing,  the 
appetite  is  capricious  and  finally  fails  altogether,  and  nutri- 
tion becomes  seriously  impaired.  The  tongue  is  pale  and 
flabby  and  more  or  less  coated,  and  either  constipation  is 
present,  or  constipation  alternates  with  diarrhoea. 

Chronic  coryza  is  one  of  the  least  self-limited  of  all 
diseases,  running  on  indefinitely  till  cured.  It  is  useless  to 
look  for  a  cure  short  of  several  months,  for  there  is  a  strong 
predisposition  to  acute  exacerbations  of  the  original  disease. 

In  the  earlier  stages  of  chronic  coryza  the  thermometer 
shows  little  alteration  of  temperature,  but  as  the  disease 
advances  a  kind  of  mild,  hectic  fever  is  developed  and  the 
evening  temperature  rises  one  or  two  degrees.  This  mostly 
occurs  with  delicate  children  in  whom  there  is  possibly  a 
suspicion  of  scrofula.  During  the  acute  exacerbations  the 
temperature  rises,  as  a  matter  of  course. 

The  nostrils  should  be  carefully  examined  by  a  full  light, 
and,  at  the  same  time,  the  fauces  should  be  examined  with 
equal  care.  In  infants,  rhinoscopic  examinations  are  almost 
impossible,  and  it  is  not  always  easy  to  get  older  children  to 
submit  to  them,  but  they  should  be  instituted  whenever 
practicable. 

The  diagnosis  is  easy  if  proper  care  is  used  in  the  exami- 
nation. The  teeth  should  always  be  examined,  as  the  foul 
odor  may  arise  from  dental  caves,  and  collections  of  matter  in 
the  follicles  of  the  tonsils  may  give  rise  to  similar  symptoms. 
The  differential  diagnosis  between  the  several  varieties  of 


54  CHRONIC    CORYZA. 

chronic  coryza — ulcerative,  syphilitic,  and  scrofulous — must 
be  based  upon  the  most  careful  and  thorough  investigation  of 
the  history  of  each  case;  for  the  syphilitic  and  scrofulous 
varieties  are  only  to  be  distinguished  from  the  form  dependent 
on  simple  chronic  inflammation  by  tlicir  histories.  A  seated 
pain  in  the  cheek  or  forehead  would  indicate  extension  of  the 
disease  to  the  antrum  of  Highmore  or  to  the  frontal  sinuses. 
Young  children  would  make  this  known  by  rubbing  the 
affected,  parts  against  the  pillow  or  against  the  nurse's 
shoulder. 

Very  few  children  die  from  chronic  coryza,  so  that  a  favor- 
able prognosis  must  be  given  as  far  as  life  is  concerned,  but 
it  is  a  most  obstinate  disease,  and,  even  under  the  most 
enlightened  homoeopathic  treatment,  it  requires  a  number  of 
months  to  effect  a  cure.  A  good  deal  depends  upon  the 
stage  of  the  disease  at  which  the  patient  comes  under  treat- 
ment ;  for  if  the  case  is  seen  early  the  prognosis  is  more 
favorable  than  if  the  case  has  progressed  to  atrophy  of  the 
nasal  mucous  membrane. 

In  the  management  of  the  chronic  coryza  of  infant's,  cloth- 
ing is  even  more  important  than  diet.  Flannel  undercloth- 
ing must  be  insisted  on  during  the  cold  months  of  the  year, 
and  merino  underclothing  should  be  worn  in  summer.  The 
underclothing,  even  in  summer,  should  come  high  up  on  the 
neck,  and  both  upper  and  lower  limbs  should  be  protected, 
for  countless  cases  are.  caused  and  finally  goaded  into  in- 
curability by  the  foolish  custom  of  leaving  the  legs  of  tender 
infants  ajmost  naked.  The  diet  should  be  plain,  but  nutri- 
tious, and  all  rich  foods  should  be  carefully  avoided. 

Sulphur  is  a  leading,  in  fact  an  almost  indispensible  reme- 
dy in  chronic  coryza  of  children.  It  is  indicated  in  weakly 
children  of  psoric  constitution,  for  almost  all  the  little  ones 
helped  by  this  great  polychrest  have  suffered  from  eruptions 
on  the  skin,  or  from  diarrhoea.  In  such  patients  the  skin  is 
unhealthy,  and  every  little  injury  inclines  to  suppurate  and 
to  heal  slowly.  The  nostrils  are  excoriated  and  ulcerated, 
with  profuse  discharge  of  thick,  yellowish  or  greenish  puri- 


CHRONIC    CORVZA.  55 

form  mucus,  and  frequently  the  nose  is  obstructed  by  hard, 
dry  scabs,  with  frequent  bleeding  from  the  nose.  In  almost 
every  case  the  nasal  discharges  have  an  offensive  smell. 
Sulphur  is  well  indicated  if,  in  the  progress  of  the  disease, 
the  cartilages  become  inflamed  and  swollen.  The  patient 
has  frequent  weak,  faint  spells,  with  coldness  of  the  extremi- 
ties and  even  general  chilliness  of  the  body,  and  it  has  long 
been  noticed  that  such  patients  are  very  liable  to  take  cold. 
The  30th  is  here  the  most  effective  preparation,  but  I  have 
used  Boericke  and  Tafel's  200th  with  fine  results. 

Calcarea  carbonica  is  classed  by  Jahr — in  company  with 
Sulphur  and  Silicia — as  being  one  of  the  most  reliable  reme- 
dies for  chronic  coryza.  The  fore  part  of  the  nose  is  red, 
inflamed  and  swollen  ;  The  nose  is  dry  and  of  very  offensive 
smell ;  the  nostrils  are  sore  and  ulcerated  ;  the  discharge 
may  be  thick  and  pus  like,  or  thin  and  watery.  The  mucous 
membrane  is  frequently  moist  during  the  day  and  dry  at 
night.  The  little  patient  has  a  tendency  to  enlargement  of 
the  glands,  and  profuse  sweat  is  often  present,  especially 
about  the  head  and  feet.  Patients  for  whom  Calcarea  car- 
bonica is  suitable  are  very  susceptible  to  external  influences, 
as  currents  of  air,  cold,  heat,  noise  and  excitement.  It 
is  an  additional  indication  when  the  catarrhal  irritation  ex- 
tends from  the  nostrils  to  the  air  passages  ;  hoarseness  is 
a  leading  indication.  "  No  remedy  will  be  more  frequently 
needed  in  irritations  and  sub-acute  inflammations  of  the 
mucous  membranes.  Even  in  catarrhs  which  run  on  into 
structural  degradation,  simulating  phthisis,  it  has  proved  to 
be  the  curative  remedy,  and  the  question  may  be  raised  if 
it  will  not  arrest  phthisis.  A  good  remedy  in  scrofulous 
ozsena."  (Brigham.)  I  have  almost  invariably  used  the 
orthodox  30th  dilution,  but,  as  Hughes  well  remarks,  "the 
3d  is  undoubtedly  efficacious." 

Silicia  is  one  of  the  invaluable  remedies  with  which  we 
combat  the  deep-seated,  morbid  processes  which  occasionally 
attack  the  bones  of  the  nose,  even  extending  to  the  cribri- 
fornrTplate  of  the  ethmoid  bone.      The  tip  of  the  nose  is 


56  CHRONIC    CORYZA. 

sensitive  to  contact  ;  the  mucous  membrane  is  excoriated 
and  covered  with  crusts;  ulcers  are  found  high  up  in  the 
nostrils.  It  lias  been  found  useful  in  inveterate,  dry  coryzas, 
also  in  chronic  ulceration  of  the  Sehneiderian  membrane.with 
discharge  of  acrid  water  which  makes  the  inner  nose  sore  and 
bleeding.  In  Silicia  the  coryza  is  dry  oftener  than  fluent  ; 
the  contrary  is  the  case  with  the  coryzas  of  Aurum,  Alumi- 
na, Arsenicum,  Asafcetida,  and  Baryta  carbonica.  "  The 
perspiration  on  the  head  is  more  in  Silicia  than  Calcarea, 
and  if  covered  lightly  soon  becomes  warm  ;  sweats  more 
often  towards  morning."  (Brigham.)  I  have  never  used 
Silicia  lower  than  the  1 2th  and  have  had  excellent  results 
from  the  20th  and  from  Boericke  and  Tafel's  200th  dilution. 
Kali  bichromicum  is  a  principal  remedy  for  catarrhal  in- 
flammations involving  nearly  the  entire  respiratory  tract,  as 
well  as  the  nasal  passages.  It  has  a  very  wide  range  of 
action,  and  has  probably  been  less  administered,  at  least  on 
this  side  of  the  Atlantic,  than  it  deserves.  "  It  is  one  of  the 
few  drugs  beneficial  in  caries  of  the  bones  of  the  nose,  and 
useful  in  combating  the  constitutional  effects  of  syphilis, 
when  complicated  with  catarrhal  affections  of  the  nose  and 
throat."  (Morse.)  The  Kali  bichromicum  catarrh  usually 
begins  with  a  profuse  mucous  discharge,  which  at  first  is 
clear  as  water,  but  as  the  disease  progresses  the  discharge  is 
thick,  tough  mucus,  which  finally,  on  drying,  fills  the  nose 
with  hard,  elastic  plugs.  Great  pain  is  caused  by  the  re- 
moval of  these  hardened  masses,  and  they  leave  the  nose 
very  sore.  There  is  a  great  accumulation  of  tenacious, 
ropy  mucus,  which  is  so  viscid  that  it  may  be  drawn  out 
like  a  long  thread,  and  the  pathological  state  appears  to  be 
chronic  ulceration  of  the  nasal  mucous  membrane  extending 
to  the  frontal  sinuses,  causing  violent  headache.  "  It  pro- 
duces deep  and  extensive  ulceration  ;  the  process  carried  on 
mostly  in  the  cartilages,  hardly  producing  caries  of  the 
bones.  It  is  almost  a  specific  for  perforating  ulcers  of  the 
septum,  and  many  cases  of  cure  are  on  record."  (T.  F. 
Allen.)     The  nostrils  and  upper  lips  are  excoriated,  with  sore 


CHRONIC    CORVZA.  57 

and  swollen  alse,  and  the  smell  from  the  nostrils  and  mouth 
is  very  fetid.  Kali  bichromicum  acts  best  on  fat,  light- 
haired  people,  and  an  additional  indication  is  a  concurrent 
affection  of  the  digestive  mucous  membrane,  indicated  by 
foul  tongue,  eructations,  nausea,  and  so  forth.  As  to  the 
dose,  my  experience  exactly  agrees  with  that  of  Dr.  Hughes: 
"  I  recommend  by  way  of  dose  the  first  six  dilutions.  The 
3d  is  most  commonly  used,  except  in  syphilis,  where  the 
lowest  potencies  of  this  salt  and  of  the  neutral  chromate 
have  been  employed  with  most  benefit.  In  acute  affections, 
however,  I  nearly  always  prefer  the  6th,  unless  I  give  the 
12th." 

Aurum  metallicum  is  one  of  the  chief  remedies  in  chronic 
coryza,  especially  when  the  nasal  bones  are  carious,  as  is 
often  the  case  after  abuse  of  Mercury  and  in  syphilitic 
coryza.  Still,  as  Dr.  T.  F.  Allen  remarks,  it  may  also  be 
called  for  in  catarrh  not  yet  involving  the  bones.  The  nose 
is  swollen,  red,  inflamed  and  sore  to  the  touch,  especially  the 
right  nasal  bone  and  adjoining  parts  of  the  upper  jaw  ;  there 
is  a  discharge  of  greenish  yellow,  offensive  matter.  The 
pains  in  the  bones  are  aggravated  at  night,  and  they  are 
accompanied  by  flow  of  tears.  The  nostrils  are  ulcerated, 
crusty,  agglutenated,  so  as  to  impede  respiration  ;  ulcers  in 
the  nostrils  covered  with  dry  yellow  crusts.  The  character- 
istic nasal  secretion  of  Aurum  is  thick  ;  in  the  sepia  coryza 
the  characteristic  secretion  is  water.  Dr.  Morse  remarks 
that  when  the  scrofulous  diathesis  is  marked  Aurum 
muriaticum  is  preferable  to  Aurum  metallicum.  One  would 
hardly  look  for  the  marked  mental  symptoms  of  Aurum  in 
infants,  though  I  have  observed  them  in  young  children 
associated  with  chronic  coryza.  I  have  always  used  the 
triturations  from  the  6th  decimal  to  the  12th  centesimal  and 
with  excellent  results. 

Argentum  nitricum  is  one  of  the  leading  remedies  in  both 
acute  and  chronic  coryza,  though  Dr.  T.  F.  Allen,  an  excel- 
lent authority,  says  that  "  the  number  of  Nitrate  of  Silver 
catarrhs  is  not  large."     The  coryza  is   at  first  dry ;  soon  the 


58  CHRONIC    CORYZA. 

mucous  membrane  becomes  moist,  and  later  a  thick,  yellow, 
purulent  mucus  issues  from  the  nostrils.  The  ake  are  pain- 
ful and  swollen,  the  nasal  bones  are  painful,  the  septum  is 
studded  with  bleeding  pimples  and  the  nose  itches  violently. 

The  scurfs  in  the  nose  become  exceedingly  painful  ;  if  de- 
tached they  bleed  :  bloody  and  purulent  discharge  in  the 
open  air,  which  stops  in  the  house.  The  characteristic  dis- 
charge is  white  and  pus-like,  mingled  with  clots  of  blood. 
The  coryza  is  accompanied  with  constant  chilliness,  sickly 
look,  lachrymation,  sneezing,  and  violent,  stupefying  head- 
ache. The  eyes  and  air  passages  are  so  frequently  involved 
that  Argentum  nitricum  does  little  good  if  the  nasal  pas- 
sages alone  are  affected.  Argentum  nitricum  acts  best  in 
the  dilutions  from  the  12th  to  the  30th  centessimal. 

Sepia  is  a  useful  remedy  in  catarrhs  arising  from  the  retro- 
cession of  an  eruption.  The  nose  is  inflamed  and  swollen, 
and  the  nostrils  are  angry  and  ulcerated  with  a  painful  erup- 
tion on  the  tip  of  the  nose.  There  is  obstruction  of  the  nose 
with  dry  coryza  and  loss  of  smell.  Dryness  in  the  choanae, 
though  there  is  much,  mucus  in  the  mouth.  Discharge  of 
yellowish  water  from  the  nose,  with  cutting  pains  in  the 
forehead.  "This  remedy  is  permanently  indicated  in  cases 
where  there  is  a  discharge  of  green,  bloody  mucus  from  the 
nose,  especially  when  accompanied  by  external  inflammation 
of  the  nose.  It  is  curative,  too,  in  cases  where  there  is  ulcer- 
ation high  up  in  the  nasal  fossae,  accompanied  by  loss  of 
smell"  (Morse).  Dr.  Hermann  Gross  remarks  that  in  the 
Sepia  coryza  putrid,  subjective  odor  predominates,  while  in 
the  Sulphur  coryza  objective  stench  from  the  nose  predomi- 
nates. I  have  used  Sepia  as  low  as  the  12th  centesimal,  but 
have  had  the  finest  results  from  the  30th. 

Alumina  is  one  of  the  first  remedies  to  be  considered  in 
chronic  dry  coryza  when  the  mucous  membranes,  both  nasal 
and  aural,  are  broken  down  by  ulceration,  especially  in  scrof- 
ulous children.  Such  children  are  often  chlorotic  and  prone 
to  obstinate  constipation.  The  nose  is  red,  swollen  and 
painful  to  the  touch;  the  nostrils  are  sore  and  scurfy;  and 


CHRONIC    CORYZA. 


59 


the  nasal  mucous  membrane  is  ulcerated,  with  discharge  of  a 
thick,  yellowish  mucus,  or  expulsion  of  yellowish-green  scabs. 
The  nose  is  stopped  at  night  with  dryness  of  the  mouth,  and 
the  septum  is  swollen  and  painful  to  the  touch.  The  throat 
is  dry,  especially  on  waking  from  sleep ;  the  voice  is  thick 
and  husky,  and  mucus  accumulates  in  the  posterior  nares. 
Itching  of  the  dorsum  and  of  the  alae  is  an  additional  indi- 
cation, and  patients  for  whom  Alumina  is  suitable  take  cold 
on  the  slightest  exposure,  yet  feel  better  in  the  open  air.  I 
have  never  given  Alumina  lower  than  the  30th  in  this  or  in 
any  other  disease. 

Baryta  carbonica  is  useful  for  the  chronic  coryza  of  chil- 
dren with  enlarged  glands  and  large  abdomens,  weak  both  in 
body  and  mind.  The  nose  and  upper  lip  are  swollen,  and 
the  nostrils  are  very  dry  with  frequent  sneezing.  The  Baryta 
carbonica  coryza,  however,  is  predominantly  fluent — the  di- 
rect opposite  of  Silicia — and  the  discharge  is  thick,  yellowish 
and  profuse.  I  have  noted  that  Baryta  carbonica  is  of  little 
use  unless  the  external  nose  is  involved  in  the  malady.  This 
remedy  has  always  been  given  by  me  in  the  6th  decimal  trit- 
uration, and  I  have  seen  excellent  results  from  it. 

Lycopodium  is  one  of  the  most  reliable  of  our  remedies 
for  the  dry  form  of  chronic  coryza,  with  much  sneezing 
during  the  day ;  at  night  the  nose  is  completely  stopped, 
with  dryness  of  the  nose  and  burning  headache.  The  nose 
is  obstructed  high  up,  with  almost  complete  closure  of  the 
nostrils  at  night,  so  much  so  that  the  patient  breathes  with 
open  mouth  and  protruding  tongue.  The  morbid  action 
frequently  extends  to  the  frontal  sinuses,  with  frontal  head- 
ache and  thick,  yellow  discharge,  which  is  at  the  same  time, 
acrid  and  excoriating.  The  irritation  is  prone  to  extend  to 
the  air-passages,  causing  cough  with  loose  expectoration,  and 
the  coryza  then  becomes  somewhat  fluent.  This  remedy  is 
suitable  for  children  who  take  cold  easily,  and  who  are 
troubled  with  derangement  of  the  alimentary  tract,  and  of 
this  derangement  the  production  of  flatus  is  the  most  prom- 
inent symptom.     Lycopodium    is  a   most   important   agent 


fio  CHRONIC    CORYZA. 

when  chronic  coryza  has  extended  to  the  air-passages,  taking 
an  ulcerative  action  and  simulating  pulmonary  consumption. 
The  remedy  acts  best  in  the  30th  dilution,  and  seems  to  be 
of  but  little  value  below  the  12th  centesimal. 

Lachesis  is  used  in  chronic  coryza  of  the  severest  kind, 
syphilitic  and  mercurial  as  well  as  the  still  worse  mercurio- 
syphilitic.  The  leading  indication  for  Lachesis  is  a  profuse 
watery  running  from  the  nose,  accompanied  by  great  sore- 
ness and  swelling.  The  mucous  membrane  of  the  nose  is 
swollen  and  bluish,  and  the  nostrils  are  raw  and  bleed  easily. 
The  nose  is  full  of  scabs,  and  the  discharge  is  pus  mingled 
with  blood,  or  there  may  be  an  extremely  copious  discharge 
of  watery  mucus.  At  the  same  time,  the  throat  inclines  to 
a  low  grade  of  inflammation  resulting  in  plastic  exudation, 
and  the  glands  of  the  neck  are  swollen  and  tender.  Epis- 
taxis  occasionally  appears,  and  all  the  symptoms  are  worse  in 
the  afternoon  and  after  sleeping.  Lachesis  acts  well  in  all 
the  dilutions  from  the  12th  to  the  200th;  I  have  mostly  used 
the  30th. 

Graphites  is  suitable  for  children  of  lymphatic  tempera- 
ment who  are  subject  to  herpetic  eruptions  of  the  skin.  Con- 
stipation is  frequently  present,  and  the  patients  easily  take 
cold  if  exposed  to  a  draught  of  air.  Catarrh  with  obstruc- 
tion of  the  nose  ;  severe  stuffed  catarrh,  with  much  nausea 
and  headache,  without  vomiting;  fluent  coryza,  with  frequent 
sneezing,  with  pains  in  the  sub-maxillary  glands;  heat  in  the 
forehead  and  face.  Dryness  of  the  nostrils,  or  alternate 
flowing  and  dryness  ;  dry  scabs  with  sore  or  cracked  and 
ulcerated  nostrils;  bloody  mucus  from  the  nose,  alternating 
with  expulsion  of  dry  scurfs;  discharge  of  thick,  fetid  mucus. 
This  remedy  has  usually  been  given  in  the  12th  dilution,  but 
I  have  had  the  best  results  from  the  30th. 

Kali  carbonica  is  suitable  for  anajmic  children  of  cachetic 
appearance,  with  puffy  swelling  over  the  upper  eyelids,  espe- 
cially in  the  morning.  Obstruction  in  the  nasal  passages, 
making  it  impossible  to  breathe  through  the  nostrils  when  in 
a  warm  room ;  the  patient,  however,  can  breathe  through  the 


CHRONIC    CORYZA.  6 1 

nostrils  in  the  open  air.  The  external  nose  is  red  and  swollen 
with  sore,  crusty  nostrils,  or  the  nostrils  are  raw  and 
bleeding.  Fetid,  yellow-green  discharge  from  the  nostrils  ; 
according  to  Hughes  the  characteristic  discharge,  is  profuse 
and  thin.  The  30th  dilution  is  most  used,  though  good 
cures  have  been  effected  with  the  12th  centesimal   dilution. 

Kali  hydriodicum  is  a  principal  remedy  in  chronic  coryza 
of  the  nasal  passages  and  frontal  sinuses  when  occurring  in 
syphilitic  children,  or  in  those  poisoned  with  mercury. 
Ulceration  of  the  internal  nose,  involving  the  frontal  sinuses 
and  antrum  highmore  ;  the  nose  is  red  and  swollen  with  con- 
stant discharge  of  acrid,  watery,  colorless  liquid,  with  violent 
lachrymation  ;  anxious  expression  and  restlessness  ;  discharge 
of  burning,  corroding  matter  from  the  nose  ;  the  inflamma- 
tion extends  into  the  eyes  and  there  is  much  conjunctivitis  ; 
the  characteristic  discharge  is  copious  and  watery,  but  it  does 
not  excoriate.  I  have  always  given  this  remedy  in  material 
doses,  never  higher  than  the  3d  decimal  dilution. 

Nitric  Acid  is,  according  to  Dr.  T.  F.  Allen,  a  very  potent 
remedy  in  syphilitic  catarrhs  of  the  nose  and  throat,  also 
when  such  cases  are  complicated  with  mercurial  poisoning. 
"  I  have  derived  more  real  satisfaction  in  seeing  the  prompt 
and  lasting  effects  of  this  drug,  not  only  in  syphilitic  catarrhs 
but  lichen,  ulcers,  glandular  affections,  falling  of  the  hair, 
etc.,  etc.,  than  from  anyother  remedy.  I  think  it  is  oftener 
indicated  than  any  other,  especially  before  the  bones  become 
much  affected.  I  have  occasion  to  use  it  every  day  in  dis- 
pensary practice,  and  invariably  the  report  is  great  improve- 
ment. The  malar  bones  become  sore  and  painful  ;  soreness 
and  bleeding  of  the  inner  nose;  the  nostrils  are  ulcerated, 
blood  and  bloody  matter  are  blown  out  of  them,  with  un- 
pleasant smell.  Nasal  mucus  goes  down  into  the  throat;  in- 
flamed and  swollen  alae  nasi,  acrid  matter  from  the  nose  at 
night  ;  discharge  of  thick  nasal  mucus,  corroding  the  nostrils  ; 
severe  catarrh,  with  swelling  of  the  upper  lips  and  especially, 
night  cough  ;  stuffed  catarrh  with  dryness  of  the  throat  on 
empty  swallowing.     I  have  never  used  Nitric  acid  higher  than 


CHRONIC    CORYZA. 

the  [2th  centesimal,  though  it  would  certainly  act  well  in 
much  higher  dilutions. 

Cyclamen  Europaeum  is  highly  recommended  in  chronic 
coryza  when  the  patient  sneezes  a  good  deal  with  profuse 
discharge,  and  rheumatic  pains  in  the  head  and  ears.  "  I  had 
a  tine  illustration  of  the  curative  powers  of  Cyclamen  in  such 
cases  with  my  colleague,  Malaise,  in  Liege  ;  the  patient  was 
a  lady  of  upwards  of  sixty  years  old,  and  had  been  suffering 
from  catarrh  for  years  ;  it  disappeared  in  less  than  twenty- 
four  hours,  to  the  astonishment  of  everybody  "  (Jahr). 

( )ther  remedies  are  Hepar  sulphuris  in  scrofulous  cases 
where  there  is  great  sensitiveness  and  the  patient  is  chilled 
by  the  slightest  draft  of  air — also  in  cases  in  which  Mercury 
has  been  abused  ;  the  nose  is  swollen  and  painful,  like  a  boil, 
and  the  nasal  bones  are  painful  to  the  touch,  the  discharges 
are  thick  and  pus-like,  and  sometimes  tinged  with  blood. 
Iodium  for  chronic  coryza  in  cachectic,  emaciated  children  of 
scrofulous  habit  with  enlarged  and  indurated  glands ;  the 
nose  is  painful  and  swollen,  with  fetid  secretions  which  at 
times  become  a  clear  and  continuous  stream.  Mercurius 
iodatus  for  syphilitic  and  scrofulous  children  with  induration 
and  swelling  of  the  glands  ;  the  nasal  bones  are  inflamed  and 
the  nostrils  are  sore  and  crusty  ;  the  nasal  discharge  is  a 
tough,  white  or  yellowish  mucus  which  forms  mostly  about 
the  posterior  nares  and  adjoining  parts  ;  profuse,  acrid,  long- 
lasting  discharges  which  excoriate  the  nostrils  and  upper  lip 
Arsenicum  iodatum,  when  the  little  patient  has  the  tubercu- 
lar diathesis  ivith  alternate  chills  and  heat  of  the  body ; 
discharge  of  very  irritating,  watery  mucus,  corrosive 
and  copious  ;  at  times  this  discharge  is  scanty  and 
thick,  sometimes  it  is  tenacious  and  frothy.  Stannum 
metallicum  for  severe  catarrh  with  copious  expectora- 
tion of  thick,  gray-green  mucus,  mixed  with  blood.  Anti- 
monium  crudum,  when  the  external  nose  is  sore  and 
painful,  the  nostrils  angry,  puffy  and  crusty,  with  a  discharge 
of  thick  yellow  mucus.  Hydrastis  for  ozrena  with  bloody, 
purulent  discharge,  or  chronic  coryza  with   thick,   tenacious 


CHRONIC    CORYZA.  63 

secretions,  more  from  the  posterior  nares,  dropping  down  in- 
to the  throat.  Ailanthus  for  coryza,  with  rawness  inside  the 
nostrils ;  chronic  nasal  catarrh,  with  difficult  breathing 
through  the  nostrils  ;  the  whole  nose  and  upper  lip  covered 
with  very  thick,  grayish-brown  scabs.  Asafcetida  for  pains  in 
the  bones  of  the  nose,  with  a  greenish  offensive  discharge, 
worse  at  night.  Berberis,  for  chronic  coryza  of  the  left  side, 
extending  into  the  antrum  of  Highmore,  with  purulent  yel- 
low or  greenish  discharges. 

Additional  remedies  are  Ammonium  carbonium,  Ammo- 
nium muriaticum,  Natrum  carbonium,  Natrum  muriaticum 
and  Magnesia  muriatica. 

Aphorisms. 

1.  Chronic  coryza  of  infants  is  common,  but  it  is  ex- 
ceedingly difficult  of  cure. 

2.  The  best  means  of  preventing  chronic  coryza  is  to  at- 
tend to  all  cases  of  acute  coryza,  even  those  which  seem  to 
be  insignificant. 

3.  Chronic  coryza  has  little  or  no  tendency  to  cure  itself, 
the  earlier  the  patient  is  attended  to,  the  more  rapid  will  be 
the  cure. 


CHAPTER  IV. 


Spasm  i  >f  the  Glottis. 


Few  diseases  have  received  so  many  names  as  spasm  of 
the  glottis,  and  in  this  case,  as  in  many  others,  "  words 
without  knowledge  darken  counsel,"  and,  to  use  the  forcible 
language  of  John  Fletcher,  "the  alliance  between  nosology 
and  nonsense  is  too  palpable  to  escape  the  meanest  capacity." 
It  has  been  called  "  inward  fits  "  by  the  vulgar,  as  if  the  word 
"inward"  conveyed  the  slightest  idea  of  the  locality  of  the 
disease,  though  Trosseau  and  Pidoux,  who  style  it  "  internal 
convulsions,"  almost  sanction  the  name.  With  equal  incor- 
rectness it  has  been  styled  "goitre  of  infants,"  "suffocative 
catarrh "  and  "  laryngeal  asthma."  Millar,  who  claims  to 
have  been  its  first  observer,  calls  it  after  himself,  and  Kopp, 
who  claims  the  same  distinguished  honor,  does  the  same 
thing.  Boerhaave  styles  it  "asthma  puerorum  ;"  Hufeland 
calls  it  "  catalepsis  pulmonum,"  and  Pagenstecher  "  asthma 
dentientium."  It  has  been  called  "  false  croup,"  "  cerebral 
croup"  and  "spasmodic  croup,"  and  Dr.  Marshall  Hall  calls 
it  "croup-like  convulsions."  Bouchut  names  it  "phreno- 
glottism,"  Eberle  makes  one  smile  with  "  carpo-pedal 
spasms,"  and  Mason  Good,  whose  system  of  nomenclature 
is  incomparably  the  most  complicated  we  possess,  calls  it 
"  laryngismus  stridulus,"  which,  however,  seems  likely  to  be 
the  classic  title  of  the  disease.  It  has  no  affinity  to  asthma, 
croup  or  catarrh,  and  I  shall  use  the  familiar  name  of  spasm 
of  the  glottis  which  conveys  some  definite  idea  to  the  mind, 
and  which  is  sanctioned  by  some  of  the  best  of  the  French 
writers  who  speak  of  "  spasme  de  la  glotte." 

Spasm  of  the  glottis  may  be  defined  to  be  a  spasmodic 


SrASM    OF    THE    GLOTTIS.  65 

contraction  of  the  muscles  which  narrow  the  glottis — namely, 
the  two  thyro-arytenoid,  two  lateral  crico-arytenoid,  and  the 
arytsenoideus  muscles — and  this  narrowing  of  the  glottis  is 
accompanied  in  very  severe  cases  by  spasmodic  action  of  the 
diaphragm  and  intercostal  muscles.  As  a  result  there  is  a 
succession  of  crowing,  stridulous  inspirations  with  a  feeling 
of  suffocation  in  the  larynx,  commencing  suddenly,  lasting 
at  first  for  a  brief  period,  and  ceasing  suddenly,  usually  with 
a  fit  of  crying.  The  attack  is  unaccompanied  by  cough  or 
any  other  evidence  of  laryngeal  or  thoracic  disease,  and  as 
the  disease  advances  other  convulsive  symptoms  appear — 
strabismas  distortion  of  the  face  and  general  convulsions, 
and  peculiar  convulsions  of  the  hands  and  feet  mark  the 
more  advanced  stages.  Should  the  two  posterior  crico- 
arytenoid muscles  be  affected,  the  very  first  attack  would 
necessarily  result  in  complete  cessation  of  respiration  and 
consequent  death. 

The  most  discordant  views  have  prevailed  as  to  the  nature 
of  this  disease.  Etmuller,  who  wrote  in  1697,  speaks  of  the 
"suffocative  convulsions  of  infants"  arising  either  from 
spasm  of  the  muscles  closing  the  glottis  or  paralysis  of  those 
opening  it.  Richa  and  Verdries,  in  the  beginning  of  the 
eighteenth  century,  thought  it  was  a  laryngeal  cramp  caused 
by  swelling  of  the  thymus  gland.  In  1769,  John  Millar  wrote 
on  the  disease,  but  as  he  confounded  it  with  catarrhal  laryn- 
gitis, and  possibly  with  diphtheritic  croup,  we  merely  gather 
that  he  writes  of  laryngeal  diseases  running  their  course  with 
attacks  of  suffocation  and  often  ending  in  death.  In  1795, 
Wichmann  defined  the  disease  to  be  a  non-inflammatory  form 
of  croup — a  purely  nervous  affection — without  alteration  of 
the  mucous  membrane.  In  1830,  Kopp  published  his  well- 
known  work  in  which  for  the  first  time  he  endeavored  to 
give  an  anatomical  basis  to  the  etiology  of  this  disease.  The 
cause,  according  to  this  writer,  is  always  hypertrophy  of  the 
thymus  gland  compressing  the  nerves  supplied  to  the  larynx, 
and  this  view  was  very  generally  held  by  medical  writers  for 
a  number  of  years.    In  1836,  Ley  announced  that  the  disease 


66  SPASM    OF    THE    GLOTTIS. 

arose  from'  the  pressure  of  enlarged  glands  on  the  pneumo- 
gastric  or  recurrent  nerves  causing  paralysis  of  the  abductors 
of  the  larynx.  Rilhet  and  Barthez,  and  indeed  most  of  the 
French  writers,  vaguely  describe  it  as  being  a  "neurosis," 
while  Valleix  doubts  the  propriety  of  classing  it  as  a  distinct 
disease.  In  1841,  Marshall  Hall,  in  his  famous  work,  "The 
Nervous  System,"  referred  this  disease  in  all  cases  to  reflex 
causes.  "  It  is  excitation  of  the  true  spinal  or  excito-motory 
system.     It  originated  in — 

I. —  1.  The  trifacial 'in  teething. 

2.  The    pneumogastric  in    over-  or    improperly- fed 

infants. 

3.  The  spinal  nerves  in  constipation,  intestinal  disor- 

der, or  catharsis.     These  act  through  the  me- 
dium of 
II. —      The  spinal  marrow,  and 
III. —  1 .  The  inferior  or  recurrent  laryngeal,  the  constrictor 
of  the  larynx. 
2.  The  intercostals  and  diaphragmatic,  the  motors  of 
respiration." 
Two  years  later,  Elsiisser  announced  his  notable  discovery 
of  the  connection  between  rachitis  and  spasm  of  the  glottis, 
though  he  erred  in  attributing  the  latter  always  to  pressure 
on  the  brain  when  the  child  lay  on  its  back.     In  1852,  Bednar 
published  the  results  of  thirty-nine  post-mortem  examinations 
of  children  who  had  suffered  from  enlarged  thymus  glands, 
of  which  number  but  fifteen  had  suffered  from  spasm  of  the 
glottis  during  life,  concluding  that  the  disease  did  not  depend 
upon  thymic  hypertrophy.     In    1858,  Bednar's  observations 
were  strongly  confirmed   by  Friedleben,  in   spite   of  which 
Abelin,  in    1868,  maintained  the  old  view,  that  spasm  of  the 
glottis  often  has  its  origin  in  swelling  of  the  thymus  gland, 
professing  to  ground  the  opinion  on  his  post-mortem  exami- 
nations.     Professor   George    B.   Wood    attributes    it    to   a 
"general  morbid  excitability  of  the  nervous  system,  directed 
especially  to  the  muscles  of  the  glottis,"  and  Dr.  P.  W.  Bird 
considers  that  "  it  is  not  an  independent  disease,  but  merely 


SPASM     OF    THE    GLOTTIS.  61/ 

a  collection  of  symptoms  consequent  on  disturbance  of  the 
nervous  system  in  general,  and  of  the  respiratory  nerves  in 
particular."  Later,  Sir  Dominic  Corrigan  stated  the  opinion 
that  the  disease  was  caused  by  a  material  change  in  the 
cervical  position  of  the  spinal  cord,  and  Dr.  Charles  West 
maintains  that  it  is  often  caused  by  the  irritation  of  teething. 
Several  distinct  influences  are  concerned  in  the  production 
of  this  disease,  and  upon  a  proper  appreciation  of  these 
influences  successful  treatment  will  depend.  Many  cases,  as 
Dr.  John  Clarke  long  ago  pointed  out,  depend  upon  an 
irritation  of  the  brain,  and  this  irritation  is  most  likely  the 
result  of  a  local  congestion  near  the  origin  of  the  pneumo- 
gastric  nerve.  In  support  of  this  view  which  is  fast  gaining 
ground,  we  have  the  undoubted  fact  that  many  cases  of 
spasm  of  the  glottis  are  preceded  by  well-marked  symptoms 
of  cerebral  disease ;  and  in  cases  of  disease  of  the  medulla 
oblongata  external  pressure  has  been  known  to  cause  the 
disease.  It  is  well  to  remember,  however,  that  the  morbid 
appearances  seen  after  death  are  frequently  not  the  cause  of 
the  spasm  of  the  glottis,  but  the  result  of  the  sudden  apncea. 
Many  cases  depend  upon  a  rachitic  condition  of  the  bones 
of  the  skull — the  "  craniotabes  "  of  Elsasser.  Sir  William 
Jenner  noticed  that  rickets  existed  in  every  case  of  spasm  of 
the  glottis  that  he  saw,  save  only  two  cases,  and  in  ninety- 
six  cases  of  spasm  of  the  glottis  examined  by  Lederer, 
rachitic  softening  of  the  cranial  bones  existed  in  ninety-two. 
In  this  class  of  cases  there  are  probably  changes  in  the  nutri- 
tion of  the  brain  as  one  result  of  the  rachitic  dyscrasia,  and 
the  spasm  of  the  glottis  is  caused  by  the  reflex  influence  of 
the  morbid  change  in  the  cerebral  mass.  Strumous  disease 
of  the  cervical  and  bronchial  glands  may  cause  spasm  of  the 
abductors  of  the  larynx,  which  is  the  essence  of  the  disease 
under  consideration,  by  obstructing  the  venous  circulation  in 
the  neck,  and  thus  giving  rise  to  irritation  of  the  brain,  which 
is  again  reflected  upon  the  laryngeal  muscles.  Again,  some 
medical  writers  distinguish  an  acute  and  a  chronic  form  of 
spasm  of  the  glottis  ;  the  acute  form  comprising  the  cases  in 


68  SPASM     OF    THE    GLOTTIS. 

which  the  spasms  recur  frequently,  and  in  which  death  by 
suffocation  often  occurs  after  a  few  paroxysms;  the  chronic, 
those  which  have  few  paroxysms  at  comparatively  long 
intervals. 

Spasm  of  the  glottis  is  a  disease  of  northern  climates  and 
of  the  winter  season  ;  and  the  mild  air  of  summer  is  a  most 
powerful  adjuvant  in  the  cure.  Out  of  forty-one  cases 
Henoch  noticed  thirteen  in  the  month  of  March,  and  Dr. 
Gee  confirms  these  observations,  for  of  65  cases  observed,  58 
were  in  the  first  half  of  the  year  and  only  5  in  the  second 
six  months.  The  following  figures  show  the  number  of 
these  cases  occurring  in  each  month  :  January,  3,  February, 
11,  March,  7,  April,  13,  May,  16,  June,  8  (total  58)  ;  July,  o, 
August,  1,  September,  o,  October,  1,  November  1,  Decem- 
ber, 2  (total,  5).  Gee  and  Flesch  simultaneously  advanced 
the  theory  that  the  increased  susceptibility  to  the  disease  is 
to  be  attributed  to  the  exalted  nervous  condition  of  the 
children,  resulting  from  the  long  confinement  indoors.  It 
seems  to  be  rare  in  France,  for  when  Rilhet  and  Barther 
published  their  first  edition  they  had  seen  but  one  case,  and 
they  were  acquainted  with  but  one  other,  published  by 
Constant  in  the  Bulletin  de  TJicrapentique  ;  when  they  issued 
the  second  edition  of  their  work  they  had  seen  only  nine 
cases  in  all.  It  is  more  common  in  Germany,  and  still  more 
common  in  Great  Britain,  for,  during  the  twenty  years  from 
1857  to  1876  inclusive,  the  Registrar-General  reports  7,318 
deaths  under  ten  years  of  age,  and  37  deaths  from  ten  to 
seventy-five  years  of  age.  Dr.  Copland  says  that  he  has  had 
as  many  as  three  cases  under  treatment  at  the  same  time  ; 
Ley  reports  having  met  with  over  twenty  cases ;  and  Dr. 
Charles  West  mentions  thirty-seven  of  which  he  has  pre- 
served some  record.  Dr.  Marshall  Hall  observes  that  "with- 
in the  short  space  of  one  month  I  have  seen  five  cases  of 
croup-like  convulsions."  Dr.  Condie  speaks  of  it  as  being 
common  in  the  United  States,  while  Dr.  J.  F.  Meigs  re- 
marks: "  I  do  not  think  it  is  a  common  disease  in  Philadel- 
phia, though  it  is  certainly  not  extremely  rare,  since  I  have 


SPASM    OF    THE    GLOTTIS.  69 

seen  four  cases  myself  and  know  of  the  occurrence  of  two 
other  cases  that  proved  fatal,  and  of  two  cases  of  recovery." 
The  writer,  whose  practice  is  largely  among  children,  has 
treated  twenty-eight  cases  and  has  heard  of  many  more  in 
the  practice  of  his  medical  friends. 

Spasm  of  the  glottis  is,  as  a  general  rule,  a  disease  of  the 
first  dentition,  though  the  writer  lately  had  a  case  in  which 
the  patient  was  five  years  old,  and  Meigs  and  Pepper  remark 
that  they  had  one  very  rare  case  in  which  the  patient  was 
seven  years  of  age.  The  English  Registrar-General,  how- 
ever, a  few  years  ago  reported  3  cases  in  which  the  patient 
was  no  less  than  seventy-five  years  old.  Vogel  remarks  that 
the  disease  makes  its  appearance  with  the  eruption  of  the 
first  tooth  and  disappears  with  that  of  the  last,  adding  that 
it  occurs  much  oftener  with  the  cutting  of  the  incisor  teeth, 
in  the  first  half  year  of  life,  than  with  that  of  the  canine  and 
molar  teeth.  Gerhard  assigns  for  this  disease  the  period 
between  the  fifth  and  twenty-fourth  month,  and  he  says  it 
is  very  rare  after  dentition  terminates.  Romberg  relates 
that  one  of  his  own  children  was  attacked  with  violent 
spasm  of  the  glottis  on  the  second  day  after  birth,  but  it 
only  occurred  in  a  single  paroxysm  and  did  not  return ;  and 
this  distinguished  writer  thinks  that  the  chief  proclivity  to 
this  disease  is  manifested  from  the  sixth  to  the  fourteenth 
month,  children  of  three  or  four  years  being  exceptions. 
Heines  says  that  of  226  cases  which  he  attended,  174  were 
in  the  first  year  of  life  and  the  remaining  52  between  the 
second  and  third  years.  Rilliet  and  Barthez,  whose  experi- 
ence was  but  limited,  observed  this  disease  almost  exclusive- 
ly in  infants  of  the  age  of  three  weeks  to  a  year  and  a  half, 
and  Flesch  states  that  it  is  rare  after  the  twenty-first  month. 
Heffen  remarks  that  the  disease  is  rare  before  the  close  of 
the  fourth  month,  and  he  thinks  that  the  majority  of  cases 
occur  between  the  age  of  four  months  and  the  close  of  the 
second  year  ;  but  if  the  disease  is  not  developed  till  during 
the  second  year  and  is  disposed  to  be  tedious,  it  may  last  for 
a  longer  or  shorter  period  beyond  the  limit  named.     He  has 


;o  SPASM     01     Till      GLOTTIS. 

further  noted  that  if  it  occurs  after  the  close  of  the  third 
year  it  is  less  intense  than  during  the  first  years  of  life,  and 
he  instances  a  mild  case  lately  seen  in  a  boy  eight  years  of 
age.  Of  thirty  cases  taken  indifferently  from  the  practice  of 
his.  Meigs  and  Pepper  and  from  various  authors,  13  were 
six  months  or  less  of  age,  1 1  between  six  months  and  a 
year,  4  between  one  and  two  years  of  age,  1  of  two  and  1  of  4 
years  of  age  ;  so  that  of  these  thirty  cases  four-fifths  were  un- 
der one  year.  In  Morell  McKenzie's  31  cases  the  ages  at 
which  the  attacks  occurred  were  as  follows:  from  birth  I  case, 
at  4  months  1  case, at  5  months  6  cases,  at  6  months  5  cases,  at 
7  months  7cases,  at  9  in  mths  }  cases,  at  io  months  1  case,  at 
1  1  month  2  cases,  at  fifteen  months  3  cases,  at  seventeen 
months  1  case,  and  at  23  months  1  case.  In  31  out  of  37  cases 
observed  by  Dr.  Charles  West  the  disease  occurred  between 
the  age  of  six  months  and  two  years  ;  and  in  48  cases  Dr. 
Gee  found  1  at  six  months,  19  from  six  to  twelve  months,  16 
from  twelve  to  eighteen  months,  and  12  from  eighteen 
months  to  two  years.  Henoch  saw  sixty-nine  children  with 
spasm  of  the  glottis,  and  39  were  hetween  the  ninth  and 
thirtieth  months,  and  22  between  the  second  and  ninth 
months,  and  Salathe  saw  24  cases,  4  in  newlyborn  infants, 
9  in  those  of  from  one  to  six  months  old,  6  in  those  from 
six  to  twelve  months  old,  4  from  one  to  th"ee  years,  one  in 
a  child  twelve  years  old.  Wunderlich  thinks  that  the 
chronic  form  mostly  occurs  between  the  fourth  and  tenth 
months,  and  the  acute  form  from  the  age  of  eighteen  months 
to  nine  years  ;  and  ITerard  has  an  almost  unique  experience, 
for  all  his  patients  were  over  two  years  of  .age,  and  two  of 
them  were  between  three  and  four  years  old.  Of  the  writer's 
28  cases,  eleven  were  less  than  six  months,  sixteen  between 
six  months  and  a  year,  and  one  was  five  years. 

The  following  tables  compiled  from  the  English  Registrar- 
General's  Reports  by  Dr.  Morell  Mackenzie,  showing  the 
number  of  deaths,  for  the  twenty  years  from  1857  to  1876 
inclusive,  from  the  disease  occurring  at  different  ages,  gives 
the  most  conclusive  evidence  as  to  the  importance  of  age  as 
a  predisposing  cause. 


SPASM     OF     THE    GLOTTIS. 


71 


Analysis  of  the    English  Registrar-General's  Reports    on 
the  Mortality  from  Spasm  of  the  Glottis  : 

CHILDREN  UNDER   IO  YEARS  OF  AGE. 


Years  of  A 

GE. 

Totals 

Under 

1 
Year. 

1. 

2.           3- 

4- 

From 
5  to  10 
Years. 

1,437 
2,915 

691 
1,305 

152        94 
213        97 

60 
63 

123 

63 

83 

Grand  Total    7,31s 

4,402 

2,086 

365      I91 

151 

ADULTS. 


Totals 

Years  of 

Age. 

10 

15 
1 

20  1  25      35 

122 

222 

45 

1 
3 

4 

55 

1 



1 

65 

1 
_± 

5 

75 

13 
24 

5 
7 

3 

Grand  Total 

37 

12 

1 

3        4       4 

3 

After  age  comes  sex  as  a  most  influential,  predisposing 
cause  in  this  disease.  The  Registrar-General's  Report  just 
quoted  gives  2,547  females  against  4,771  males  in  the  first 
table,  and  in  the  second,  which  speaks  of  persons  from  10  to 
75  years  of  age,  the  numbers  were  13  females  to  24  males. 
Of  the  16  cases  seen  by  Herard  and  Rilhet  and  Bartlez,  12 
occurred  in  boys  and  4  in  girls,  while  of  183  collected  by 
Larent,  in  which  the  sex  was  noted,  125  occurred  in  boys 
and  58  in  girls.  In  Steiner's  226  cases  the  relative  propor- 
tion of  the  sexes  was  150  boys  to  j6  girls,  while  Vogel  in  his 
15  cases  had  11  boys  against  4  girls.  Of  the  28  cases  under 
my  own  care,  19  were  boys  and  9  were  girls.  Of  Mackenzie's 
37  patients,  21  were  boys  and  16  girls,  while  in  Dr.  Gee's  48 
cases,  34  were  boys  and  14  girls.  Almost  the  only  statistics 
in  contradiction  to  these  are  furnished  by  Salathe,  who  found 
only  eleven  boys  in  twenty-four  cases,  while  of  297  cases 
seen  at  the  hospital  for  sick  children,  London,  166  were 
males,    and    131    females,    making   a    total    of     177    males, 


Ilerard 

saw     1 6    cases, 

12 

Larent 

"      1S3       " 

125 

Steiner 

"     226 

150 

Henoch 

'•       61       •' 

49 

Werner 

'         26       '• 

15 

Hachmann 

14 

12 

Pagensticher 

18 

'4 

Kopp 

10 

9 

72  SPASM    OF    THE    GLOTTIS. 

and  144  females  ;  but  these  observations  are  too  isolat- 
ed and  the  numbers  too  few  to  invalidate  the  very  conclu- 
sive figures  already  given.  Steffen  gives  the  following  table, 
which  "  alone  amounts  to  a  demonstration,"  though  the 
Registrar-General's  figures  being  larger  are  still  more  con- 
clusive : 

g    boys   and     4  girls. 

"     5S  " 

•'     76  " 
•'     12 


554  3§6  168 

The  precise  cause  of  this  greater  predisposition  of  the 
male  sex  to  spasm  of  the  glottis  is  still  an  unsolved  mystery. 

Still  another  predisposing  cause  of  spasm  of  the  glottis  is 
supposed  to  be  heredity.  Romberg  says  that  in  one  family 
he  attended  two  children  who  labored  under  this  complaint 
(one  of  whom  died),  after  three  other  children  of  the  same 
family  had  fallen  victims  to  it  ;  and  Gerhardt  reports  a  fam- 
ily of  nine,  all  of  whom  suffered  from  spasm  of  the  glottis, 
and  seven  of  these  died.  Dr.  Ley  quotes  four  instances 
from  various  authors  in  which  three  children  in  each  family 
had  the  disease,  and  Powell  saw  one  family  of  thirteen  chil- 
dren, all  of  whom  had  had  attacks  of  this  malady.  Werner 
saw  two  cases  each  in  four  families,  and  three  children  in 
another  family  seized  one  after  another,  and  two  of  the 
writer's  children  have  had  severe  attacks,  but  neither  died. 
But  the  most  striking  illustration  of  this  phase  of  the  disease 
is  that  given  by  Reid,  in  which,  out  of  a  family  of  thirteen 
children,  ten  died  of  the  disease  and  only  one  escaped  an 
attack. 

Do  these  cases  prove  an  actual  hereditary  descent  from 
parent  to  child  ?      Romberg,  a  great  authority   on   nervous 


SPASM    OF    THE    GLOTTIS.  73 

diseases,  is  quite  certain  that  it  does,  for  he  says :  "  There 
can  be  no  doubt  of  the  existence  of  an  hereditary  disposi- 
tion ;  in  many  families  several  and  even  all  the  children, 
though  they  may  have  been  differently  brought  up,  both  as 
to  residence  and  food  are  attacked  with  a  spasm  of  the 
glottis.''  Bouchert  remarks  that  "  it  is  sometimes  observed 
amongst  children  born  of  a  delicate,  excitable,  or  nervous 
mother  ;  and  what  is  a  strong  proof  of  the  original  disposi- 
tion of  this  disease  is  its  successive  appearance  amongst  all 
the  children  of  the  same  family  ;"  and  Vogel,  after  observ- 
ing that  "  the  hereditary  character  of  spasm  of  the  glottis 
is  interesting,"  goes  on  to  say  that  "  the  mothers  of  the 
children  whom  I  have  treated  for  this  disease  were  all  of  a 
tolerably  excitable  nature,  and  often  complicated  the  child's 
disease  by  indulging  in  their  habitual  hysterical  outbreaks." 
Morell  Mackenzie  thinks  that  the  many  cases  in  which  the 
disease  has  attacked  large  families  do  not  really  prove  its 
actual  hereditary  descent,  but  that  they  "strongly  point  to 
consanguineous  influence  ;  and  he  points  out  that  the  appar- 
ently strong  proof  afforded  by  the  cases  of  Gerhardt  and 
Reid  may  all  be  explained  on  the  supposition  that  in  each 
instance  all  the  children  were  exposed  to  the  same  anti- 
hygienic  influences.  He  illustrates  this  view  of  the  question 
by  the  following  case  :  "  A  gentleman  of  slightly  strumous 
organization  married  a  healthy  woman,  and  had  two  boys 
and  two  girls.  They  none  of.  them  suffered  from  laryngis- 
mus, but  the  influence  of  the  father's  constitution  was  shown 
in  the  children  by  enlarged  cervical  glands,  hypertrophied 
tonsils  and  early  decay  of  the  teeth.  The  family  grew  up, 
all  married  and  all  had  children.  In  two  of  the  families  one 
child  had  laryngismus,  and  in  one  family  two  children  suf- 
fered from  the  disease,  and  in  one  family  three  children 
were  affected.  In  all  four  families  the  children  were  slightly 
rickety."  Steffen  correctly  points  out  that  all  the  cases 
which  have  been  adduced  to  prove  a  real  hereditary  predis- 
position to  this  disease  do  not  prove  a  true  descent  from 
parent  to  child,  but  only  that  several   children   of  a  family 


74  SPASM    OF    THE    GLOTTIS. 

suffered  from  it — which  is  a  very  different  thing.  So  that 
till  descent  from  parent  to  child  is  clearly  proved,  we  must 
conclude  that  the  spasm  of  the  glottis  is  not  hereditary. 

The  prevailing  opinion  of  those  authors  who  have  devoted 
most  time  to  the  investigation  of  this  disease  is  that  children 
subject  to  it  are  mostly  delicate  and  feeble,  and  that  it 
affects  most  violently  those  of  scrofulous  and  rachitic  con- 
stitution. On  the  other  hand  it  has  often  been  observed  in 
children  of  the  most  robust  and  vigorous  constitution,  and 
some  of  the  writer's  patients  were  pictures  of  health.  The 
proportion  of  children  who  suffer  from  both  spasm  of  the 
glottis  and  rickets  is  undoubtedly  very  large,  and  Steffen, 
writing  from  European  observations,  is  probably  correct  in 
asserting  that  the  healthy  constitution  of  the  body  which 
presents  favorable  soil  for  the  commencement  of  the  disease 
consists  in,  by  far,  the  larger  number  of  cases  in  a  predispo- 
sition to  rachitis.  Dr.  Gee  reports  rickets  present  in  48  out 
of  his  50  cases,  all  of  which,  however,  occurred  among 
the  poor,  in  whom  all  the  causes  of  rickets  would  most  likely 
be  in  full  operation ;  Flesth  says  that  three-fourths  of  his 
cases  were  rickety,  and  of  Mackenzie's  31  cases,  all  of  which 
occurred  in  private  practice;  17  were  slightly  rachitic,  while 
2  were  markedly  rachitic.  Steffen  asserts  that  in  by  far  the 
larger  number  of  cases,  say  at  least  nine-tenths,  rickets  give 
rise  to  spasm  of  the  glottis.  But  one  of  the  writer's  28  cases 
suffered  in  any  degree  from  rickets,  and  that  one  case  only 
to  a  very  small  extent  ;  and  it  is  quite  certain  that  on  the 
North  American  continent  the  co-existence  of  rickets  and 
spasm  of  the  glottis  is  much  rarer  than  in  Europe,  where,  in 
a  very  large  proportion  of  the  population,  the  causes  of 
rachitis  are  more  actively  at  work  than  they  are  on  this  more 
favored  continent.  Elsasser  looked  upon  craniotabes,  which 
only  appears  in  well  developed  rachitis,  as  being  almost 
always  the  cause  of  spasm  of  the  glottis  ;  but,  though  Steffen 
says  that  "spasm  of  the  glottis  may  be  expected  when  it 
(craniotabes)  is  present,"  the  writer  has  never  noted  cranio- 
tabes and  spasm  of  the  glottis  occurring  in  the  same  patient, 


SPASM    OF    THE    GLOTTIS.  75 

though  he  has  seen  28  cases  of  the  latter  in  his  own  practice 
and  many  more  in  the  practice  of  others.  Again,  he  has 
seen  a  large  number  of  cases  of  craniotabes,  none  of  which 
had  ever  suffered  from  spasm  of  the  glottis,  so  that  he  looks 
upon  the  connection  between  the  two  morbid  states  as  being 
at  least  problematical.  Condie  thinks  that  "  it  is  very  cer- 
tain that,  after  the  most  careful  analysis  of  the  observations 
on  record  in  reference  to  rachital  softening  of  the  cranium, 
that  in  the  majority  of  instances,  spasm  of  the  glottis  occurs 
in  cases  where  not  a  trace  of  craniotabes  exists."  Curiously 
enough,  Steffen  himself  admits  that  spasm  of  the  glottis  "  in 
no  way  depends  on  it  (craniotabes),  and  does  not  necessarily 
follow  ;  "  and  Mackenzie,  while  admitting  that  the  two 
morbid  states  often  co-exist,  says  that  "  it  does  not  follow 
that  rachitis  is  to  be  regarded  as  the  cause  of  laryngismus." 
On  the  other  hand,  Vogel,  a  great  authority,  considers  that 
the  connection  between  craniotabes  and  spasm  of  the  glottis 
has  been  "  satisfactorily  demonstrated  "  by  Elsasser,  but 
he  differs  from  Elsasser  as  to  the  precise  modus  operandi. 
Elsasser  held  that  the  pressure  of  the  pillow  on  the  soft 
occiput  was  competent  to  cause  spasm  of  the  glottis,  while 
Vogel  contends  that  "  not  the  softness  and  depressibility  of 
the  occiput  per  se,  but  their  effects,  should  be  regarded  as 
the  exciting  causes,  as  the  meninges  may  thereby  degener- 
erate  into  an  abnormally  congested  condition." 

More  influential  than  craniotabes  in  the  causation  of 
spasm  of  the  glottis  is  rachitis  of  the  bones  of  the  thorax. 
Children  who  are  born  or  brought  up  in  a  small,  or  damp,  or 
cold  house,  who  live  in  close  or  unwholesome  air,  who  are 
badly  or  insufficiently  nourished,  and,  above  all,  who  are 
deprived  of  sunshine,  are  apt  to  suffer  from  disorder  of  the 
processes  of  digestion  and  assimilation,  and  in  these  unfor- 
tunate children  rachitis  is  developed  with  melancholy  facility 
— even  in  those  whose  parents  had  not  suffered  from 
rachitis  in  their  childhood.  Steffen,  in  his  ingenious  explana- 
tion, points  out  that  an  abnormal  irritability  of  the  nervous 
system  is  one  of  the  most  marked  features  of  spasm    of  the 


?6  SPASM    OF    THE    GLOTTIS. 

glottis.  This  abnormal  irritability  is  greatly  increased,  if 
not  entirely  caused,  by  the  rachitic  state  in  the  following 
manner:  the  lateral  flattening  of  the  walls  of  the  thorax 
leads  to  a  marked  diminution  of  the  capacity  of  the  chest, 
and  that,  in  its  turn,  leads  to  a  more  superficial  respiration, 
and  thence  to  increased  frequency  of  respiration  ;  this,  of 
course,  at  once  necessitates  an  increased  activity  of  the 
heart,  greater  wear  and  tear  of  the  system,  and  consequent 
irritation  of  the  brain  and  entire  nervous  system.  Suddenly 
then,  in  such  children,  spasm  of  the  glottis  occurs,  and  in 
these  cases  it  is  not  so  much  the  bones  that  are  at  fault  as 
the  deep-seated  disturbance  of  nutrition  and,  above  all,  the 
greatly  increased  irritability  of  the  nervous  system,  without 
which  spasm  of  the  glottis  is  unlikely  to  take  place. 

Many  excellent  observers  held  to  the  purely  nervous  nature 
of  spasm  of  the  glottis.  Mason  Good  asserts  that  it  is 
"  purely  and  idiopathically  nervous,"  and  Gregory  says  "  it  is 
caused  by  a  high  degree  of  irritability  in  the  nervous  system 
of  the  child."  Felix  von  Niemeyer  holds  that  "it  depends 
upon  a  morbid  excitement  of  the  nerves  by  means  of  which 
contraction  of  the  muscles  of  the  glottis  is  effected,"  adding 
"  that  by  uniform  shortening  of  all  the  muscles  at  once,  the 
vocal  chords  become  tightly  stretched,  and  the  glottis  is 
closed."  But  he  considers  that  this  irritation  may  be  due  to 
pressure  along  some  part  of  the  course  of  one  of  these  nerves, 
or  to  centric  irritation  of  the  root  of  the  vagus.  Scrofula 
of  the  tracheal  and  bronchial  glands  is  present  in  a  consid- 
erable proportion  of  cases  of  spasm  of  the  glottis,  and  these 
swollen  glands  probably  act  by  pressing  on  the  recurrent 
nerves.  If  this  pressure  is  continuous,  a  constant  wheezing 
is  present,  but  usually  the  pressure,  depending  on  the  amount 
of  blood  in  the  glands,  is  moderate  and  variable,  so  that 
respiration  is  sufficiently  easy.  In  most  of  these  glandular 
cases  the  bones  of  the  thorax  are  affected  at  the  same  time, 
and  here  Steffen's  ingenious  explanation  would  hold  good. 
Finally,  all  experienced  observers  will  concur  in  the  opinion 
of  the  lamented  Felix  von  Niemeyer,  "In  most  cases  the 
pathogeny  of  this  disease  is  obscure." 


SPASM    OF    THE    GLOTTIS.  JJ 

The  exciting  causes  are  very  various.  In  general  terms  it 
may  be  said  that  any  force  capable  of  acting  upon  the 
general  morbid  excitability  of  the  nervous  system  will 
produce  the  disease  in  those  predisposed  to  it.  The  irrita- 
tion of  teething  stands  in  the  front  rank,  though  Morell 
Mackenzie  thinks  that  the  influence  of  teething  in  the 
causation  of  spasm  of  the  glottis  is  "  enormously  over-rated," 
an  opinion  in  which  the  author  cannot  concur.  Spasm  of 
the  glottis  is  rarely  the  first  manifestation  of  morbid 
dentition,  it  is  usually  preceded  by  irritation  of  the  brain,  or 
disorder  of  the  alimentary  canal.  Sometimes  a  child  has  an 
attack  of  spasm  of  the  glottis  whenever  it  cuts  a  tooth,  but 
the  first  of  these  attacks  is  usually  the  most  severe.  Dis- 
orders of  digestion  are  also  a  frequent  cause,  and  hence  it 
often  occurs  in  children  fed  by  hand.  Weaning,  according 
to  Romberg,  appears  to  favor  the  development  and  continu- 
ation of  the  disease.  Sometimes  it  depends  upon  habitual 
constipation,  and  it  may  be  caused  by  the  sudden  suppression 
of  the  diarrhoea  of  dentition.  No  single  agency  occupies  a 
more  prominent  position  in  the  popular  pathology  than 
"  worms,"  and  this  omnipresent  cause  is  capable  of  exciting 
an  attack  of  spasm  of  the  glottis  in  those  predisposed  to  it. 
The  disease,  again,  may  depend  upon  some  deep-seated 
cerebral  affection,  and  two  of  the  writer's  most  severe  cases 
were  caused  by  congestion  of  the  base  of  the  brain.  It  may 
precede  hydrocephalus,  and  its  occurrence  in  a  child  who  is 
not  teething  and  who  is  free  from  disorders  of  the  digestive 
system,  is  always  a  suspicious  circumstance.  The  mere  act 
of  swallowing  occasionally  excites  an  attack,  and  Prof.  G.  B. 
Wood  says  that  infants  are  sometimes  attacked  with  it  when 
tossed  playfully  in  the  air.  The  writer  has  seen  it  follow 
infantile  emotions  as  fretting  and  fright,  and  in  such  cases 
the  disease  is  very  liable  to  recur. 

The  briefest  and,  at  the  same  time,  the  most  graphic 
account  of  the  disease  is  that  given  by  Dr.  John  Clarke  in 
his  "Commentaries  on  the  Diseases  of  Children."  "The 
child    is    suddenly   seized    with    a    spasmodic    inspiration, 


78  SPASM    OF    THE    GLOTTIS. 

consisting  of  distinct  attempts  to  fill  the  chest,  between 
each  of  which  a  squeaking  noise  is  often  heard.  The  eyes 
stare,  and  the  child  is  evidently  in  great  distress;  the  face 
and  the  extremities,  if  the  paroxysm  continue  long,  become 
purple  ;  the  head  is  thrown  backward,  and  the  spine  is  often 
bent  as  in  opisthotonos,  at  length  a  strong  expiration  takes 
place,  a  fit  of  crying  generally  succeeds,  and  the  child, 
evidently  much  exhausted,  generally  falls  asleep." 

Spasm  of  the  glottis  often  appears  suddenly  and  wholly 
without  warning,  though  the  little  one  has  sometimes  been 
drooping  for  a  few  days,  has  lost  appetite,  and  has  been 
fretful  and  peevish.  The  lighter  attacks  merely  consist  in 
crowing  inspiration,  and  this  excites  little  or  no  alarm.  If 
the  attack  takes  place  during  the  day  the  little  one  becomes 
pale,  throws  itself  backward,  and  moves  the  hands  and  feet 
uneasily.  Suddenly  the  crowing  inspiration  appears,  the  eyes 
roll  up  in  the  head,  and  the  thumbs  are  turned  in  but  not 
clenched  tightly.  At  once  the  child  cries  out,  and  the  attack, 
which  had  lasted  but  a  few  moments,  is  over.  The  little  one 
is  cross  for  a  while,  but  soon  regains  it  equanimity.  If  these 
light  attacks  occur  in  the  night  time  the  child  wakes  up,  has 
the  attack  and  then  falls  asleep,  and  unless  the  mother 
chances  to  be  awake  the  disease  may  go  on  unnoticed  for 
quite  a  time. 

In  severer  cases  the  first  attack  is  apt  to  take  place  at 
night — though  Steffen  says  this  is  an  error — very  often 
towards  midnight  when,  after  the  first  deep  sleep  has  passed 
away,  the  child  suddenly  starts  up  with  great  difficulty  of 
breathing,  inspiration  being  accompanied  by  a  shrill  crowing 
noise,  which  some  observers  compare  to  that  of  croup,  but 
which  really  differs  very  much  from  it.  The  patient  becomes 
much  alarmed,  and  indeed  the  paroxysm  is  of  the  most 
urgent  nature,  and  real  danger  is  present.  A  few  crowing 
inspirations  take  place,  or,  more  rarely,  some  very  laborious 
and  audible  expirations  resembling  a  paroxysm  of  emphyse- 
matous breathing.  Suddenly  a  more  or  less  complete  closure 
of  the   glottis   takes   place,  the    crowing   sound  ceases,  the 


SPASM     OF    THE    GLOTTIS. 


79 


respiratory  movements  of  the  chest  are  arrested,  and  the 
thorax,  the  diaphragm,  and  even  the  anterior  abdominal 
muscles  become  fixed  and  immovable.  The  crowing  inspira- 
tions which  precede  the  glottis  seizure  are  usually  accompa- 
nied by  a  flushed  countenance,  but  the  face  now  becomes 
pale  and  livid,  and,  if  the  paroxysm  lasts  long,  this  deepens 
into  a  cyanotic  hue.  The  child  throws  its  head  back,  the 
eyes  roll  in  the  head  or  stare  straight  forward,  the  great 
vessels  of  the  neck  become  turgid,  the  mouth  opens  and  the 
nostrils  dilate,  and  a  cold  sweat  suffuses  the  forehead  and 
even  the  entire  head. 

In  many  instances  general  convulsions  appear,  especially 
if  the  paroxysm  is  severe  and  of  long  duration.  All  the 
muscles  of  the  arms  and  legs  are  affected,  the  hands  are 
tightly  closed  and  the  thumbs  pressed  into  the  palm,  and  at 
times  even  the  wrists  are  bent  inwards.  Sometimes  the 
hands  are  tumefied  and  reddened,  and  in  almost  all  cases 
pain  is  caused  by  an  attempt  at  extension.  The  spasm  also 
affects  the  feet,  the  great  toe  is  drawn  apart  from  the  other 
toes  which  are  bent  inwards,  and  the  foot  is  rigidly  extended, 
or,  as  in  a  recent  case  of  the  writer's,  fixed  in  the  form  of 
talipes  varus.  These  so-called  "  carpo-pedal "  contractions 
are  most  likely  accompanied  by  great  pain.  The  general 
convulsions,  even  the  episthotonos,  evidently  depend  upon 
the  convulsions  of  the  glottis,  for  they  appear  and  disappear 
with  them,  and  the  more  exquisite  forms  partake  of  the 
character  of  epilepsy.  Frequently  the  fceces,  less  frequently 
the  urine,  are  passed  involuntarily  during  the  attack.  The 
paroxysm  terminates  with  one  or  more  whistling  inspirations, 
and  the  respiration,  at  first  very  irregular,  assumes  its 
accustomed  rhythm,  consciousness  returns,  the  action  of  the 
heart  becomes  stronger  and  more  regular,  the  cyanotic  hue 
of  the  face  gives  place  to  pallor  which,  in  its  turn,  gives  way 
to  the  normal  color,  and  the  child  is  itself  again. 

In  some  cases,  happily  rare,  the  paroxysm  assumes  the 
form  of  a  sudden  spasm,  almost  without  sound,  which  does 
not  relax  till  the  child  is  dead.  These  are  the  cases  in  which 
the  posterior  crico-arytenoid  muscles  are  most  likely  affected 


So  SPASM    OF    THE    GLOTTIS. 

Morcll  Mackenzie  says  that  "  the  first  attack  of  laryngis- 
mus often  comes  on  at  night — frequently  towards  eleven  or 
twelve  o'clock  ;  "  but  Stelfen  asserts  that  "the  supposition 
that  spasm  of  the  glottis  has  a  special  predeliction  for  the 
night  season  is  an  error  held  by  very  many."  Amongst  that 
many  must  be  included  the  present  writer,  for  a  very  large 
majority  of  his  cases  had  the  first  attack  in  the  night  season, 
and  most  of  the  subsequent  paroxysms  occurred  during  the 
night.  An  attack  is  very  short,  say  from  five  seconds  to 
two  minutes,  though  the  extreme  danger  makes  the  time 
seem  much  longer,  and  attacks  said  to  last  half  an  hour  will 
be  found  to  be  composed  of  a  succession  of  paroxysms,  with 
very  brief  intermissions,  just  sufficient  to  throw  a  re-inforce- 
ment  of  oxygen  into  the  blood.  The  light  attacks  are 
usually  short,  the  severe  attacks  are  usually  long,  and  the 
paroxysms  show  a  strong  inclination  towards  progressive 
severity  in  regard  to  intensity,  duration  and  recurrence,  and, 
consequently,  danger.  When  the  symptoms  are  of  the 
character  described  as  belonging  to  the  severer  variety  of 
the  disease,  the  paroxysm  is  almost  certain  to  be  followed 
by  others  in  increasingly  rapid  succession,  and  the  child  may 
die  almost  at  once.  I  had  one  case  in  which  a  fine,  healthy 
boy  of  twenty  months  had  the  first  and  only  paroxysm,  in 
the  morning  after  his  bath  ;  the  glottis  closed  almost  with- 
out sound,  and  the  little  one  died  in  less  than  a  minute.  On 
the  other  hand,  I  had  two  cases  in  which  the  little  ones  had 
but  one  single  paroxysm  of  great  severity,  followed  by  per- 
fect recovery,  without  any  return  of  the  disease.  Still,  as 
Romberg  long  ago  noticed,  it  is  only  in  very  rare  cases  that 
recovery  or  death  takes  place  during  the  first  days  of  the 
illness.  The  duration  of  the  affection  depends  very  much 
on  the  exciting  cause.  It  is  rare  that  a  child  has  one  single 
attack  ;  generally  several  paroxysms  follow  each  other  in 
rapid  succession,  after  which  the  disease  may  disappear  in 
consequence  of  the  cutting  of  some  teeth,  or  as  the  result  of 
treatment.  The  first  attack  is  usually  the  most  severe, 
though  when  a  second  paroxysm  rapidly  follows  the  first 


SPASM     OF    THE    GLOTTIS.  8l 

one,  almost  before  the  child  has  recovered  from  it,  the  like- 
lihood is  that  the  second  will  be  both  long  and  severe.  A 
strong  child,  previously  in  good  health,  may  withstand 
several  scores  of  paroxysms,  provided  they  are  not  all  of  the 
more  severe  type  and  do  not  come  in  too  rapid  succession. 
Thus  Dr.  Benedict,  of  Philadelphia,  reports  a  case,  with  the 
characteristic  spasm  of  the  hands  and  feet,  which  lasted  for 
four  months  and  a  half,  and  was  followed  by  perfect 
recovery. 

As  the  child  grows  older  the  predisposition  to  the  disease 
declines,  and  though  the  paroxysms  may  still  recur,  they  are 
not  nearly  so  severe,  and  the  danger  to  life  is  evidently 
diminished.  The  explanation  is  that  the  laryngeal  cartilages 
are  firmer,  the  larynx  is  larger  and  especially  wider,  and  the 
entire  nervous  systefn  is  less  irritable  and  impressible. 
When  the  paroxysms  do  appear  they  merely  consist  in  a 
feeling  of  suffocation  and  slight  difficulty  in  swallowing,  with 
slightly  irregular  respiration,  but  no  crowing  or  whistling 
inspiration.  Carpo-pedal  convulsions  have  never  been  ob- 
served in  children  over  five  years  of  age,  and  they  are  some- 
what rare  from  the  end  ofjihe  third  to  the  end  of  the  fifth 
year. 

During  the  paroxysm  it  is  a  matter  of  some  difficulty  even 
to  feel  the  pulse  or  ausculate  the  heart,  and  it  is  still  more 
difficult  to  make  thermometric  observations.  I  have  been 
unable  to  find  any  such  observations  in  the  libraries  to  which 
I  have  access,  and  can  give  but  a  few  made  by  myself  under 
exceptional  circumstances.  Alluding  to  this  point,  Vogel 
remarks  "  temperature  of  the  extremities  is  much  more  likely 
to  be  diminished  than  increased,"  and  Steffen  says  that  "  in 
view  of  the  overloading  of  the  venous  system  the  body,  and 
especially  the  extremities  are,  as  a  rule,  cool  and  livid,"  but 
neither  of  these  skilled  observers  appears  to  have  used  the 
thermometer.  In  mild  cases,  then,  the  temperature  varies 
from  980  F.  to  98.4  F.,  that  is,  a  trifle  below  the  temperature 
of  the  same  child  when  in  health,  just  what  one  would  expect 
in  a  disease  which  is  not  only  non-febrile,  but,  from   the 


82  SPASM     OF    THE    GLOTTIS. 

loading  of  the  venous  system,  positively  shows  a  temperature 
below  the  healthy  standard.  In  severe  cases  of  spasm  of  the 
glottis  in  children  not  suffering  from  any  febrile  disease,  the 
thermometer  placed  in  the  axilla  showed  a  temperature  of 
i 1-.;°  F.  shortly  after  the  commencement  of  the  spasm,  and 
as  it  advanced  the  temperature  was  lowered  till  it  fell  to 
96.50  1".  In  one  instance  I  succeeded  in  placing  a  very 
strong  New -York  thermometer  in  the  hand  of  a  child  just 
before  the  carpo-pedal  spasm  clenched  the  fingers,  and  it 
showed  a  temperature  of  96.50  F.  at  a  time  when  the  axil- 
lary temperature  was  97. 5°  F.  nearly.  I  was  unable  to  make 
observations  on  the  feet  in  any  of  these  cases,  but  I  have  no 
doubt  but  that  they  were  cooler  than  the  hands.  I  made 
careful  observations  in  two  children  who  were  suffering  from 
the  fever  of  dentition  at  the  time  that  they  were  attacked 
with  spasrrt  of  the  glottis,  with  the  following  results:  The 
thermometer,  which  had  shown  a  temperature  of  ioo°  F.  on 
the  previous  day  and  100.20  F.  shortly  before  the  attack, 
showed  a  temperature  of  98. 50  F.  soon  after  the  commence- 
ment of  the  attack  of  spasm  of  the  glottis,  and  at  its  height 
the  temperature  was  97. 5°  F.,  showing  in  both  cases  an 
average  of  1°  F.  above  those  children  who  were  not  suffering 
from  teething  fever  at  the  time  of  the  paroxysm  of  spasm  of 
the  glottis.  Observations  made  by  auscultating  the  larynx 
are  still  a  desideratum,  but  I  have  been  so  intent  on  making 
thermometric  observations  that  I  have  only  made  a  very  few 
in  auscultation,  and  these  are  too  few  and  too  imperfect  for 
publication. 

Notwithstanding  all  that  has  been  written  as  to  the  thymic 
origin  of  this  disease,  no  characteristic  lesion  can  be 
discovered  after  death,  and  the  gland  is  sometimes  increased 
in  size,  at  other  times  it  is  smaller  than  usual,  or  it  may  be 
almost  entirely  absorbed.  But  hypertrophy  of  the  thymus  is 
by  no  means  common,  and  chronic  inflammation  is  quite  rare. 
No  alteration  whatever  can  be  discovered  in  the  laryngeal 
nerves,  nor  in  the  laryngeal  structure  of  the  muscles;  while  the 
mucous  membrane  is  slightly  reddened  only  in  the  rare  cases 


SPASM    OF    THE    GLOTTIS.  83 

in  which  the  child  suffered  from  laryngeal  catarrh  as  well  as 
spasm  of  the  glottis,  so  that,  as  far  as  the  larynx  is  concerned, 
the  purely  neurotic  nature  of  the  malady  is  amply  confirmed 
by  post-mortem  examinations.  Craniotabes  is  present  in 
many  cases,  though  Steffen  says  this  is  by  no  means  the  rule, 
and  next  in  frequency  you  meet  with  rachitis  of  the  ribs. 
The  tracheal  and  bronchial  glands  are  frequently  affected, 
but  the  lesions  are  not  characteristic.  Frequently  they  are 
more  or  less  swollen  and  caseated,  and  this  is  particularly 
noticeable  in  the  bronchial  glands  which  are  sometimes 
found  to  be  mere  collections  of  cheesy  tubercles.  At  times, 
solitary  glandular  indurations  may  be  found  in  the  intestines, 
and  in  such  cases  tuberculosis  is  apt  to  be  present  in  the 
lungs.  Congestion  of  the  brain  and  of  its  membranes  have 
often  been  noticed,  but  these,  though  at  times  predisposing 
causes  of  the  spasm  of  the  glottis,  are  quite  as  often  effects 
of  it,  and  this  is  especially  the  case  with  the  frequently- 
observed  cedema  of  the  brain.  Steffen  remarks  that  the 
softening  of  the  medulla  oblongata  has,  very  occasionally, 
been  demonstrated,  and  at  times  the  brain  has  been  found 
inflamed  or  even  softened.  Some  observers  have  noted  that 
the  pneumo-gastric  nerve  was  hardened,  others  have  seen  it 
softened. 

Congestion  of  the  lungs  with  engorgement  of  the  right  side 
of  the  heart  is  common,  doubtless  due  to  the  asphyxia,  and 
cedema  of  the  lungs  is  very  often  present.  Emphysema  of 
the  lungs  is  also  found  as  a  result  of  the  irregular  and 
spasmodic  respiration,  but,  as  Dr.  J.  Lewis  Smith  points  out, 
"  slight  emphysema  occurring  in  the  upper  lobes  is  common 
in  infants,  even  those  who  have  had  no  serious  disease  of  the 
respiratory  organs."  The  blood  is  darker  than  usual,  and 
Bednar,  and  also  Rilliet  and  Barthez  found  the  heart  and 
great  thoracic  vessels  filled  with  black  fluid  blood,  though 
Loeschner  asserts  that  he  has  always  found  the  thoracic 
organs  somewhat  anaemic.  Finally,  more  or  less  congestion 
of  the  intestinal  mucous  membrane  is  usually  present,  and 
indeed  any  organ  of  the  body  may  be  congested  as  a  result 
of  spasm  of  the  glottis. 


84  SPASM     OF    THE    GLOTTIS. 

Attention  to  Dr.  Chcyne's  pathognomonic  sign  will  tend 
to  prevent  errors  in  diagnosis,  "  a  crowing  inspiration,  with 
purple  complexion,  not  followed  by  cough"  It  has  been 
confounded  with  croup,  but  in  croup  the  difficulty  of 
breathing  is  permanent  or  nearly  so,  and  it  affects  expiration 
as  well  as  inspiration  ;  but  in  spasm  of  the  glottis  it  is  inspi- 
ration which  is  affected.  In  croup  respiration  is  affected, 
though  with  difficulty ;  but  in  spasm  of  the  glottis  respiration 
is,  for  a  brief  time,  positively  stopped.  Croup  is  accompa- 
nied by  severe  cough,  but  this  symptom  is  wholly  absent  in 
spasm  of  the  glottis.  In  croup  the  child  is  hoarse,  but 
hoarseness  is  not  an  integral  part  of  spasm  of  the  glottis. 
Croup  usually  follows  exposure  to  the  cold  ;  spasm  of  the 
glottis  has  little  dependence  on  that  cause  of  disease.  Lastly, 
croup  is  usually  accompanied  by  fever,  and  it  has  convulsions 
only  when  about  to  terminate  fatally,  while  spasm  of  the 
glottis  has  no  fever  and  has  a  most  characteristic  species  of 
convulsion. 

Spasm  of  the  glottis  may  be  confounded  with  cedema  of 
the  glottis,  but  the  last  mentioned  developes  gradually, 
whereas  spasm  of  the  glottis  arises  suddenly.  The  experi- 
enced finger  can  easily  detect  the  hard  and  swollen  cherry-like 
mucous  membrane  of  the  epiglottis,  so  characteristic  of 
oedema,  while  nothing  of  the  sort  is  found  in  spasm  of  the 
glottis. 

There  is  a  close  resemblance  between  the  sounds  of 
whooping  cough  and  spasm  of  the  glottis,  but  in  the  latter 
disease  there  is  no  cough,  no  expectorations,  no  vomiting  and 
no  rattling  of  mucus  in  the  lungs.  Whooping  cough  almost 
always  has  a  catarrhal  stage  lasting  a  week  or  ten  days, 
while  spasm  of  the  glottis  rarely  has  any  prodromal  stage 
whatever. 

"  Paralysis  of  the  abductors — a  very  rare  affection  in  child- 
hood— might  be  mistaken  for  spasm  of  the  adductors,  and  it 
is  thus  important  to  carefully  distinguish  between  these  two 
conditions.  In  the  paralytic  cases  there  is,  as  Dr.  Marshall 
Hall  has  pointed  out,  "  a  constant  but  partial  closure"  of  the 


SPASM    OF    THE    GLOTTIS.  85 

glottis,  the  vocal  cords  never  being  abducted  from  their 
paralyzed  position,  but  always  leaving  a  small  opening 
through  which  the  air  can  pass.  In  spasm  of  the  adductors 
on  the  other  hand,  there  is  inconstant  but  complete  closure  of 
the  glottis ;  in  other  words,  there  is  considerable  movement 
of  the  cords,  which  are  at  one  moment  widely  separated  and 
at  another  so  closely  approximated  that  air  cannot  pass 
through  the  glottis.  The  symptom  in  the  one  case  is 
constant  dyspnoea,  increased  on  the  slightest  exertion,  whilst 
in  the  other  it  is  constant  dyspnoea,  with  complete  inter- 
mission between  the  attacks.  This,  however,  is  not  an 
absolute  taw,  for  on  three  occasions  I  have  seen  slio-ht 
Constant  stridor  in  the  case  of  children  in  whom  the  other 
symptoms  were  of  spasmodic  character,  carpo-pedal  contrac- 
tions and  convulsions  (Morell  Mackenzie). 

This  is  always  a  grave  disease,  for  even  in  mild  cases 
serious  symptoms  may  arise  and  the  prognosis  changes  at 
once,  and  Condie  remarks  that  '  a  sudden  and  very  severe 
paroxysm  may  unexpectedly  occur  at  any  moment,  particu- 
larly during  the  period  of  dentition."  Dr.  John  Clarke  says 
that  the  patient  rarely  recovers,  and  Dr.  Reid  collated  280 
cases  showing  a  mortality  of  115.  Dr.  Cheyne  and  Dr. 
Gooch  both  state  that  it  proved  fatal  in  one-third  of  those 
attacked,  and  only  one  of  the  9  cases  seen  by  Rilliet  and 
Barthez  recovered,  and  Herard  saved  but  one  out  of  seven. 
Of  Sir  Henry  Marsh's  cases,  5  recovered  and  2  died,  and  of 
Dr.  Hersch's  cases,  3  died  out  of  5 — and  one  of  the  fatal 
cases  was  complicated  with  whooping  cough.  Bouchut 
thinks  that  rather  more  then  than  one-half  die,  while  Lorent 
notes  45  deaths  of  100  cases  occurring  in  boys  and  32  deaths 
in  100  cases  occurring  in  girls.  Wunderlich  says  that  one- 
third  of  all  those  attacked,  and  the  majority  of  those  visited 
with  severe  attacks  die,  and  Steiner,  a  physician  of  vast  ex- 
perience, is  sure  that  the  great  majority  die. 

On  the  other  hand  Steffen  says  that,  if  we  include  the 
lightest  cases,  which  we  certainly  should,  the  prognosis  is,  on 
the  whole,  favorable,  and  Salathe  lost  but  2  cases  out  of  24. 


S6  SPASM     01     I  Ml'.    GLOTTIS. 

Morcll  Mackenzie  says  that  spasm  of  the  glottis  "  rare])' 
proves  fatal,"  which  is  not  by  any  means  the  general  expe- 
rience. Notwithstanding  all  these  opinions,  almost  all  of 
them  unfavorable,  the  writer's  28  cases  all  recovered  save 
two,  one  of  which  was  the  foudroyante  case  referred  to,  and 
the  same  result  may  almost  always  be  expected  from  an 
enlightened  homoeopathic  treatment. 

Spasm  of  the  glottis  is  more  dangerous  to  young  children 
than  to  older  ones,  for  in  the  latter  the  laryngeal  cartilages 
are  harder,  the  larynx  is  wider,  and  the  nervous  system  is 
less  impressible.  Children  at  the  breast  do  better  than 
those  who  have  been  weaned.  The  prognosis  is  more  favor- 
able in  girls  than  in  boys.  Emaciated  children  have  less 
chance  of  doing  well  than  well-nourished  children.  The 
lower  the  temperature  during  the  attack  the  greater  the 
danger.  The  longer  the  interval  between  the  spasms  the 
better  the  chance  of  recovery.  General  convulsions  or 
carpo-pedal  contractions  add  greatly  to  the  gloom  of  the 
prognosis.  The  danger  is  greater  when  the  malady  results 
from  intracranial  disease  than  when  it  depends  on  dentition 
or  on  some  stomach  attack.  Diarrhoea,  continued  vomiting, 
or  anything  which  lowers  the  powers  of  life,  vitiate  the  prog- 
nosis. Ryland  and  Ley  both  refer  to  bronchitis  as  an  oc- 
casional exciting  cause  of  the  disease,  while  Steffen  asserts 
that  "  acute  pneumonia  usually  effects  a  material  abatement 
and  even  complete  disappearance  of  the  laryngeal  cramp." 
Children  far  gone  in  rachitis,  especially  if  craniotabes  is 
present,  are  usually  considered  less  likely  to  recover  than 
those  of  healthy  constitution,  yet  Steffen  maintains  that 
"  the  most  favorable  cases  are  those  in  which  it  is  developed 
as  the  result  of  rachitis."  Scrofula,  which  finds  its  expres- 
sion in  swelling  and  caseation  of  the  tracheal  and  bronchial 
glands,  renders  the  prognosis  more  doubtful.  Children  who 
have  had  one  attack  should  never  be  considered  safe  till  the 
completion  of  the  first  dentition.  Long-continued  and  severe 
spasms,  with  cyanotic  face  and  symptoms  of  suffocation, 
often  presage  an  unfavorable  issue.  If  remedies  are  prompt- 
ly and  faithfully  used  by  a  physician  who  has  carefully  stud- 


SPASM    OF    THE    GLOTTIS.  87 

ied  the  disease  the  chances  of  recovery  are  much  better  than 
if  remedies  are  carelessly  used  by  a  practitioner  who  knows 
little  or  nothing  of  the  disease. 

Death  takes  place  in  three  distinct  modes.  The  first  is 
apncea,  when  the  child  is  choked  during  the  paroxysm  ;  first 
respiration  is  suspended,  then  after  a  few  hurried  beats  the 
pulse  ceases,  and  the  lungs  and  heart  are  found  to  be  flooded 
with  dark  blood.  Or  death  may  take  place  when  the  current 
of  blood  is  prevented  from  passing  from  the  brain  to  the 
heart  and  lungs,  and  if  this  state — really  congestion — is  not 
promptly  relieved,  effusion  takes  place  and  the  child  dies 
comatose.  Lastly,  death  may  take  place  from  exhaustion  ; 
the  strength  is  reduced  by  a  constant  succession  of  severe 
paroxysms,  diarrhcea  sets  in,  and  death  closes  the  scene. 

Sambucus  is  the  classic  remedy  of  our  school  for  spasm  of 
the  glottis,  recommended  before  all  others,  though  it  cannot 
be  looked  upon  as  being  the  leading  specific,  and  there  is  a 
growing  inclination  to  question  its  efficacy.  Dr.  Drysdale 
has  not  seen  any  good  effects  from  it,  while  Dr.  W.  S.  Searle, 
of  Brooklyn,  after  stating  that  Sambucus  was  the  remedy 
selected  by  Hahnemann  for  the  disease,  goes  on  to  say  that 
"  its  signal  failure  to  cure  the  large  majority  of  cases  has  led 
some  to  question  whether  the  usual  sagacity  of  the  master 
did  not  desert  him  on  this  occasion  ;"  adding  further,  "  the 
fact,  however,  does  not  prove  that  the  remedy  is  not  home- 
cepathic  to  some  modalities  of  the  disease,  and  the  trouble 
lies  in  our  failure  to  discover  these  modalities ;  not  in 
Hahnemann  nor  in  the  remedy."  Bashr  thinks  that  the 
striking  case  reported  by  Hartmann  does  not  represent  a 
high  degree  of  spasm  of  the  glottis,  while  Farrington  thinks 
that  "  its  symptoms  do  not  seem  to  point  distinctively  to  a 
spasm  of  the  glottis."  Ruddock  recommends  during  the 
attack  a  very  prompt  administration  of  Aconite,  alternated 
with  Sambucus,  for  "  fear  of  suffocation  and  dry  cough,"  but 
as  the  indications  for  Aconite  are  wholly  distinct  from  those 
for  Sambucus,  it  is  decidedly  best  to  give  the  remedy  indi- 
cated, singly  and  alone.  Hughes,  one  of  our  best  authori- 
ties, says  that  "  Sambucus  is  in  high  esteem." 


88  SPASM    OF    THE    GLOTTIS. 

The  attack  takes  place  suddenly  ;  the  patient  awakes  from 
a  kind  of  lethargy  with  the  eyes  and  the  mouth  open  ;  he 
raises  himself  in  bed  with  great  anxiety  and  dyspnoea,  the 
respiration  is  oppressed,  with  wheezing  in  the  chest,  the 
head  and  hands  are  puffed  and  bloated,  with  dry  heat  over 
the  whole  body,  no  thirst,  small,  irregular  and  intermittent 
pulse.  The  patient  tosses  about  anxiously  and  is  unable  to 
sleep.  There  is  no  cough,  and  the  attack  principally  occurs 
from  midnight  to  4  A.  M.  After  the  paroxysm,  the  child 
perspires  profusely,  and  Sambucus  is  said  to  be  the  leading 
remedy  when  the  disease  originates  in  suppressed  perspira- 
tion. Dunham  points  out  that  while  Chlorine  has  difficulty 
in  expiring,  none  in  inspiration,  Sambucus  has  the  reverse. 
Searle  gives  the  following  determining  indications:  "Burn- 
ing, red,  hot  face,  hot  body,  with  cold  hands  and  feet  during 
sleep.  On  awaking,  the  face  breaks  out  into  a  profuse 
perspiration,  which  extends  over  the  body,  and  continues, 
more  or  less,  during  the  waking  hours  ;  then,  on  going  to 
sleep  again,  the  dry  heat  returns ;  "  adding,  "should  you  ever 
meet  with  a  case  presenting  these  peculiarites,  you  may  be 
sure  Sambucus  will  cure  it,  and  nearly  as  sure  that  it 
will  fail  if  these  symptoms  are  absent."  During  the  last  few 
years  I  have  only  met  with  two  cases  in  which  Sambucus 
was  indicated,  but  the  results  were  striking  and  prompt,  and 
I  was  greatly  helped  by  Searle's  laconic  but  invaluable  indi- 
cations. Sambucus  has  usually  been  given  in  drop  doses  of 
the  1st,  2d  or  3d  dilutions,  though  Hartmann  thinks  that  a 
"  higher  attenuation  may  perhaps  do  better  and  prevent  a 
recurrence." 

Moschus  is  recommended  by  several  of  the  standard 
writers,  though  Hempel  says  that  it  acts  in  accordance  with 
the  principle  of  Contraria,  while  Hartmann  thinks  that  it  is 
very  far  from  being  a  specific  remedy.  "  Moschus  is  vari- 
ously recommended  for  this  disease,  but  we  cannot  see  its 
homteopathicity  to  it.  We  are  not  acquainted  with  any 
decided  cures  that  Moschus  has  effected  in  this  disease, 
llartmann's    statement    to  the    contrary    notwithstanding." 


SPASM    OF    THE    GLOTTIS.  89 

(Baehr.)  Drysdale  brackets  Moschus  with  Sambucus,  but 
he  has  never  seen  any  good  effect  from  either.  Searle  states 
that  it  "  is  said  to  have  cured  laryngismus,  probably  hys- 
teric in  character,"  while  Hughes  affirms  that  his  own  ex- 
perience has  led  him  to  believe  smelling  at  Moschus  to  be  the 
best  means  of  relief  during  the  paroxysm.  "  Moschus  causes 
a  spasm  of  the  throat,  larynx  and  lungs — sudden  sensation, 
as  if  the  larynx  closed  on  the  breath,  as  from  inhaling  sul- 
phur-vapor. It  is  more  applicable  to  hysterical  cases,  and 
possibly  to  spasm  of  the  glottis  during  the  course  of  dis- 
eases which  exhibit  impending  paralysis  of  the  pneumo- 
gastric  nerve."  (Farrington?)  Dr.  Pemerl,  of  Munich, 
writes:  "  If  neither  the  chest  nor  the  abdomen  is  affected, 
and  we  have  only  to  battle  against  a  reflex  irritation  of  the 
nervous  trigeminus,  I  prefer  the  exhibition  of  Moschus  1 
or  2  in  quickly  succeeding  doses,  and  usually  I  could  be 
satisfied  with  the  results  ;  but  Moschus  is  never  of  any  use 
whatever  when  abdominal  or  thoracic  affections  underlie  the 
spasmus  glottidis."  Kafka  reports  a  case  of  laryngismus 
spasmodicus,  in  a  girl  five  years  of  age,  of  light  complexion, 
with  sudden  attacks  of  crowing  and  protracted  inspiration. 
The  spasm  of  the  glottis  was  improved  by  Veratrum,  but 
cured  very  quickly  with  Moschus  12,  one  drop  every  two 
hours.  Laurie  recommends  one  globule  of  the  3d  dilution 
in  a  teaspoonful  of  water,  repeated  at  intervals  of  half  an 
hour  until  three  doses  have  been  given ;  and  subsequently 
at  intervals  of  two  hours,  until  decided  amelioration  or 
change.  For  olfaction,  as  advised  by  Hughes,  the  1st  deci- 
mal trituration  would  be  preferable. 

Aconite  is  not  even  mentioned  by  either  Hughes  or  Bsehr, 
and  Searle  omits  it  from  the  list  of  remedies — Chlorine, 
Mephitis,  Sambucus,  Moschus  and  Lachesis — of  which  he 
says,  "besides  these  five,  I  am  unable  to  find  any  remedies 
that  have  cured,  or  are  likely  to  cure,  a  case  of  true  spasmus 
glottidis."  On  the  other  hand,  according  to  Prof.  Walter 
Williamson,  Aconite  is  "specific,"  while  Hempel  says  "  we 
have  cured  more  than  one  spasm  of  the  glottis  radically  with 


90  SPASM    OF    THE    GLOTTIS. 

nothing  but  the  first  attenuation  of  Aconite  root,"  and  again 
he  says,  "  we  affirm  that  we  have  effected  cures  of  this 
disease  with  .Aconite  alone,  without  using  any  other  medicine. 
We  mix  a  drop  or  two  of  the  first  decimal  attenuation  of  the 
root  in  two  tablespoonfuls  of  water,  and  give  ten  or  fifteen 
drops  of  this  mixture  every  two  or  three  minutes,  until  the 
patient  is  decidedly  easier.  If  no  positive  relief  is  obtained 
after  giving  a  few  doses,  we  substitute  a  drop  of  the  tincture 
in  the  same  manner  as  before."  Jahr,  under  the  caption  of 
"  Spasm  of  the  Glottis,  Asthma  Thymicum,  Kopp,"  writes, 
"After  I  had  cured  my  daughter,  a  child  of  five  years,  in 
1849,  °f  this  disease,  which  set  in  one  morning  with  all  the 
frightful  symptoms  of  true  croup,  and  I  expected  every 
moment  to  see  her  perish  of  asphyxia,  in  less  than  ten 
minutes,  by  means  of  a  single  dose  of  Aeon.,  30,  three 
globules;  I  have  commenced  the  treatment  of  this  spasm  in 
every  subsequent  case  with  Aeon.,  thereby  unfortunately 
creating  a  belief  that  croup  can  be  wiped  out,  as  it  were,  by 
a  stroke  of  magic.  Not  every  case  of  spasm  of  the  glottis 
can  be  cured  so  easily  with  Aeon,  alone,  although  this 
remedy  never  fails,  if  no  complications  are  present,  to  afford 
speedy  help."  I  side  with  my  lamented  friend,  Hempel,  for 
I  have  seen  the  happiest  results  from  Aconite,  given  as  he 
directs,  in  spasm  of  the  glottis.  Aconite  is  indicated  when 
a  suffocating  cough  comes  on  suddenly  at  night  with  hoarse 
voice  and  shrill  outcry;  the  respiration  is  short  and  anxious; 
the  skin  is  dry  and  hot ;  the  pulse  is  full,  hard  and  greatly 
accelerated.  Good  results  have  been  seen  from  all  doses, 
from  the  Hempelite  mother-tincture  to  the  Hahnemannian 
30th  dilution,  but  in  acute  cases  I  have  never  given  it  higher 
than  the  1st  decimal  dilution,  while  in  protracted  cases  I 
have  used  from  the  6th  decimal  trituration  to  the  12th  cen- 
tesimal dilution. 

In  1869,  writing  on  this  disease,  I  spoke  as  follows  on  the 
use  of  Sanguinaria :  "  My  own  experience  leads  me  to  look 
upon  Sanguinaria  as  being  the  Imperial  Guard  of  all  the 
remedies  for  spasm  of  the  glottis.     After  using  this  remedy 


SPASM    OF    THE    GLOTTIS.  91 

successfully  in  the  various  forms  of  croup,  I  was  induced  to 
give  it  in  two  apparently  desperate  cases  of  spasm  of  the 
glottis  after  the  unsuccessful  use  of  Aconite,  Sambucus  and 
other  apparently  well-indicated  remedies.  I  was  gratified  to 
find  its  administration  followed  by  rapid  and  durable  cures, 
and  I  now  look  upon  it  as  being  the  first  remedy.  I  give  it 
in  the  form  of  an  acetous  syrup."  Now,  after  an  enlarged 
experience,  I  feel  still  more  confidence  in  this  little-used  but 
invaluable  remedy. 

Brilliant  cures  have  been  effected  with  Arsenicum  album, 
especially  when  the  disease  assumes  the  chronic  form.  Drys- 
dale  mentions  it  as  one  of  the  medicines  which  he  has  found, 
on  the  whole,  most  useful  in  this  disease,  and  Baehr  thinks 
that  it  deserves  our  attention  if,  as  is  often  the  case,  the 
disease  attacks  feeble  children  with  marked  symptoms  of 
cerebral  anaemia.  The  attack  is  preceded  for  several  days 
by  catarrhal  symptoms ;  the  little  patient  goes  to  sleep 
quietly,  and  the  spasm  comes  on  suddenly  in  the  night, 
threatening  suffocation  ;  the  respiration  is  short  and  hissing. 
There  is  great  anguish  with  copious  perspiration  ;  prostration 
of  strength  with  aggravation  of  all  the  symptoms  between 
midnight  and  daylight.  The  child  breathes  freely  between 
the  attacks,  but  is  languid  and  restless.  "  In  my  opinion 
Arsenicum  is  the  true  specific  for  this  disease.  Not  to 
mention  the  peculiar  sense  of  suffocation  or  constriction  in 
the  larynx,  with  stoppage  of  breath,  what  drug  has  more 
than  Arsenic  the  peculiarity  of  producing  such  a  paroxysm 
at  night,  waking  the  child  suddenly?  or  after  trifling  causes 
such  as  crying,  laughing,  getting  choked  by  a  little  food  or 
drink,  etc.?  What  drug  has  the  typical  recurrence  of  the 
first  paroxysms  at  decreasing  intervals?  the  apparently 
insignificant  prodromi  of  such  a  dangerous  disease?  the 
sudden  disappearance  of  the  spasm  by  violently  shaking  the 
child?''  (Hartmann.)  I  have  had  better  results  from  the 
30th  dilution  than  from  the  lower  preparations,  and  I  never 
saw  any  good  results  from  Arsenicum  save  in  cases  such  as 
Baehr  describes. 


02  SPASM    oi     THE    GLOTTIS. 

Belladonna  is  the  principal  remedy  when  the  brain  is 
seriously  involved,  when  the  head  is  hot  and  the  face 
alternately  flushed  and  pale,  and  all  the  symptoms  point  to 
cerebral  congestion.  It  is  of  great  service  when  the  child's 
head  is  large  and  when  the  carpo-pedal  spasms  are  present. 
Hughes  says  it  must  be  given  where  there  is  arterial  excite- 
ment and  cerebral  congestion,  and  Jahr  recommends  it 
especially  in  the  case  of  scrofulous  children.  Baehr  observes 
that  "  Belladonna  is  only  adapted  to  spasm  of  the  glottis 
when  occurring  as  a  secondary  symptom  in  other  diseases," 
but  the  force  of  the  objection  is  broken  by  the  fact  that 
spasm  of  the  glottis  is  very  often  indeed  "a  secondary 
symptom  in  other  diseases,"  but  not  the  less  dangerous  on 
that  account.  The  little  one  is  over-susceptible  to  impres- 
sions, and  this  is  aggravated  by  bright  light,  noises,  the 
slightest  contradiction,  by  dentition,  or  by  the  presence  of 
irritating  or  indigestible  substances  in  the  intestinal  canal. 
The  respiration  during  sleep  is  irregular  or  intermittent,  and 
on  falling  asleep  the  child  wakes  and  starts  as  if  frightened. 
The  sleep  is  restless,  tossing  about  the  bed,  quarrelling  in 
sleep,  talking  or  crying  out.  The  larynx,  which  had  been 
sensitive  to  pressure,  suddenly  feels  constricted  with  violent 
struggles  for  breath,  and  the  smallest  quantity  of  fluid  drank 
excites  a  spasm.  The  brain  is  excited,  the  face  red,  the  eyes 
injected  with  squinting  or  dilated  pupils,  the  teeth  are 
clenched,  and  fearful  convulsions  of  the  flexor  muscles  set 
in  ;  frequently  opisthotonic  convulsions.  "  It  seems  to  be 
indicated  by  the  characteristic  spasm  in  the  larynx,  and  may 
be  given  to  children  of  every  variety  of  constitution,  plethoric 
or  lymphatic,  scrofulous,  rickety,  etc.,  and  more  particularly 
when  bad  management  has  induced  collateral  complications 
or  cerebral  affections."  (Hartmann.)  Belladonna  has  been 
used  in  all  potencies  in  this  disease.  Thus  Dr.  E.  Clarke,  of 
Portland,  reports  a  case  in  the  North  American  Journal  of 
Iloma'opathy,  vol.  XX,  in  which  Belladonna  in  the  200th  and 
400th  dilutions  rendered  excellent  service,  and  on  the  other 
hand,    Dr.   J.   N.   Tilden,   of    Peekskill,    N.   Y.,  reports  the 


SPASM    OF    THE    GLOTTIS.  93 

following  cases,  which  are  really  model  cures,  in  the  Homcec- 
patliic  Times  for  1878: 

"Case  i. — A  delicate  child,  aet.  8  months,  artificially  fed, 
digestion  in  perfect  condition.  His  paroxysms  were  always 
precipitated  by  crying  from  anger.  They  were  characterized 
by  a  sudden  and  complete  cessation  of  respiration,  as  if  the 
rima  glottidis  were  completely  closed  to  the  entrance  of  air, 
and  accompanied  by  alarming  lividity  of  the  face,  lasting 
for  from  ten  to  twenty  seconds,  when  the  first  inspiration 
would  be  accompanied  by  a  shrill  crowing  sound  almost 
identical  with  the  characteristic  inspiration  of  whooping 
cough.  After  this  prolonged  inspiration  the  breathing  would 
be  irregular  and  sighing,  and  the  discolored  features  would 
be  followed  by  pallor,  accompanied  with  great  prostration, 
and  cold  perspiration  lasting  for  half  an  hour  or  more.  These 
alarming  attacks  occurred  at  irregular  intervals,  sometjmes 
daily,  often  at  longer  periods.  Strict  attention  to  regimen, 
abundant  out-door  recreation  was  directed,  and  Belladonna 
1st  dec.  given  internally  every  two  hours  while  awake.  A 
marked  diminution  in  the  severity  of  the  symptoms  was  at 
once  noted,  and  after  a  few  days'  treatment  the  attacks 
ceased  entirely. 

"CASE  2. — -Child,  aet.  9  months,  suffering  from  teething  and 
indigestion,  had  paroxysms  every  time  he  waked  from  sleep. 
In  this  instance  they  consisted  of  ineffectual  spasmodic 
efforts  at  inspiration,  attended  with  the  same  shrill,  crowing 
sound  mentioned  as  occurring  in  the  other  case.  This 
patient  did  not  have  so  much  congestion,  nor  were  the  par- 
oxysms followed  with  so  great  prostration  as  in  the  previous 
patient  ;  but  during  the  attacks,  which  lasted  one  or  two 
minutes,  it  seemed  as  if  the  little  fellow  must  surely  suffocate. 

"  The  difference  in  the  symptoms  noted  in  the  two  cases 
was  probably  owing  to  the  fact  that  in  the  first  case  the 
rima  glottidis  was  entirely  closed,  and  in  the  second,  though 
rigid  and  unyielding,  it  was  open  sufficiently  to  allow  the 
entrance  of  a  limited  amount  of  air. 

"  The  treatment  was  the  same  in  this  case  as  in  the  preced- 


o.j  SPASM     OF    THE    GLOTTIS. 

ing  one — Belladonna  and  the  result  was  equally  prompt 
and  satisfactory.  The  paroxysms  were  at  once  ameliorated, 
and  after  three  or  four  days  there  \ver>'  no  more  symptoms 
of  them." 

My  own  experience  with  Belladonna  in  this  disease 
decidedly  leads  me  to  favor  the  measure  dose,  though  T  have 
never  descended  to  the  1st  decimal  dilution,  having  seen 
excellent  results  from  the  3d  to  the  5th  decimal.  In  the 
intervals  of  the  paroxysms  I  have  given  the  12th  and  30th 
centesimal  dilutions  with  fine  results. 

Ruoff  and  Jahr  speak  favorably  of  Ipec.  Searle  does 
not  mention  it,  and  Pcmerl,  of  Munich,  recommends  it 
•'  when  we  find  sabilant  rouchct  with  dry,  titillating,  frequent 
and  tormenting  cough — a  morbid  state  little  likely  to  be 
found  in  pure  spasm  of  the  glottis — and  these  indications 
can « only  hold  good  when  a  laryngeal  catarrh  precedes  or 
accompanies  the  disease.  "  Ipecacuanha  has  been  mentioned 
as  a  remedy  ;  indeed  the  symptoms  justify  this  recommen- 
dation. We  should  not,  however,  overlook  the  fact  that 
asthmatic  difficulties  do  not  really  occur  in  this  disease. 
Relief  is  easily  afforded  if  a  remedy  is  given  at  the  outset, 
but  it  does  not  last,  and  we  cannot  recommend  a  remedy  as 
a  specific,  unless  it  controls  the  whole  disease.  We  admit, 
however,  that  Ipecacuanha  may  have  an  excellent  effect,  for 
the  time  at  least,  in  a  catarrh  accompanying  spasm  of  the 
glottis."     (Raehr.) 

I  have  given  Ipecacuanha  with  success  when  the  spasm  of 
the  glottis  was  excited  by  the  reflex  influence  of  indigestible 
food,  the  attack  being  preceded  by  nausea  and  vomiting  and 
even  by  purging  ;  also  when  the  disease  was  caused  by  taking 
cold,  and  thus  was  associated  with  a  catarrh  of  the  larynx. 
The  symptoms  are  rattling  in  the  trachea  and  lungs  from 
accumulated  mucus,  with  spasmodic  contraction  in  the 
laryngeal  region,  with  threatening  suffocation,  anxious  and 
short  or  sighing  respiration,  together  with  purple  color  of 
the  face  and  cramps  and  rigidity  of  the  body. 

"  As   regards    laryngismus   stridulus,  having  had    several 


SPASM    OF    THE    GLOTTIS.  95 

cases  of  it,  we  can  speak  from  experience  of  the  efficacy  of 
Sambucus  and  Ipecacuanha  in  curing  it.  We  once  had  a 
case  of  laryngismus  in  which  the  whooping-cough  super- 
vened. The  suffocative  spasms  were  of  the  most  painful 
description.  When  a  fit  of  coughing  came  on,  and  the  child 
had  at  the  same  time  an  outburst  of  passion  (the  usual 
exciting  cause  of  the  attacks  of  laryngismus  in  this  case),  the 
child  would  scarcely  have  begun  to  cough  when  he  lost  all 
power  of  respiring  altogether.  He  grew  literally  black  in 
the  face  ;  his  head  fell  backwards,  and  there  he  lay  for  some 
seconds  apparently  beyond  all  recovery.  He  revived  on 
putting  his  head  out  of  the  window,  or  dashing  cold  water 
in  his  face.  Ipecacuanha  effected  a  cure."  {British  Journal 
of  Homoeopathy,  XII,  p.  457.) 

As  to  the  dose,  Laurie  advises  to  dissolve  3  globules  of 
the  3d  dilution  in  six  teaspoonfuls  of  water;  give  a  tea- 
spoonful  every  quarter  of  an  hour,  until  three  doses  have 
been  given,  after  which  the  intervals  must  be  lengthened,  or 
the  medicine  suspended,  if  decided  improvement  or  a  cessa- 
tion of  the  symptoms  of  impending  suffocation  ensues.  I 
have  always  used  the  3d,  4th,  or  5th  decimal  triturations  in 
the  manner  recommended  by  Laurie. 

Gelsemium  sempervirens  was  introduced  to  the  profession 
by  Dr.  E.  M.  Hale,  of  Chicago,  who  considers  that  "  if  not 
a  curative  remedy,  properly,  it  will  be  a  valuable  palliative, 
used  in  drop  doses  of  the  first  dilution,  or  mother  tincture, 
frequently  repeated  ;  it  must  procure  relief  in  a  majority  of 
cases,  while  during  the  intermediate  time  it  should  be  alter- 
nated with  Belladonna,  Hyosciamus,  Arsenicum  or  Moschus." 
In  a  recent  edition  of  his  invaluable  work  he  writes  as  follows  : 
"  The  primary  effect  of  Gelsemium  is  to  paralyze  the  mus- 
cles of  the  tongue,  glottis  and  the  whole  apparatus  concerned 
in  deglutition  and  vocal  efforts,  but  this  paralysis  is  not 
attended  by  the  numbness  and  tingling  caused  by  Aconite  ; 
the  secondary  effects  of  the  drug  result  in  spasmodic  and 
tetanic  conditions  of  the  same  muscular  structures. 

You  will  be  able  to  cure  as  I  have  cured,  some  sudden  and 


g6  SPASM    OF    THE    GLOTTIS. 

alarming  paralytic  affections  of  the  throat  with  the  high  dilu- 
tions ;  while  in  spasm  of  the  glottis  and  spasmodic  croup  you 
will  be  successful  with  more  material  doses."  Ruddock  re- 
marks that  it  is  an  excellent  reserve  medicine  for  an  occasional 
acute  attack  which  does  not  yield  promptly  and  fully  to  Aco- 
nite, and  it  is  one  of  the  very  few  remedies  endorsed  by  Raue. 
The  indications  are  long  inspiration  with  croupy  sound, 
expiration  sudden  and  forcible.  Sudden  and  severe  attacks 
of  dyspnoea,  with  crowing  noise,  profuse  perspiration  and 
darkly  flushed  face. 

In  the  fifth  volume  of  the  Homceopathic  World,  Dr.  Ad- 
rien  Stokes  of  Southport,  England,  relates  two  cases  of 
spasm  of  the  glottis  cured  by  Gelsemium,  of  the  first  of 
which  the  following  is  a  summary  :  The  patient,  twenty- 
one  years  of  age,  had  had  diphtheria,  and  three  months  after- 
wards, when  first  seen  by  the  doctor,  appeared  to  suffer  from 
laryngeal  catarrh.  There  was  some  tenderness  of  the 
trachea  on  touch,  and  an  increasing  difficulty  of  inspiration 
towards  evening.  Mercurius  was  given,  but  at  midnight  the 
doctor  was  summoned,  and  found  the  patient  in  bed, 
propped  up  with  pillows,  her  hands  pressed  upon  the  bed 
beside  her,  the  face  ashy,  the  lips  livid,  and  the  countenance 
wearing  an  anxious  expression.  Respiration  was  very  diffi- 
cult, and  the  pulse  thready  and  feeble.  The  finger-nails  were 
livid,  and  the  hands  stiff.  The  larynx  was  very  tender,  and 
became  increasingly  so.  Deglutition  was  difficult,  and 
became  more  so  as  time  went  on.  The  doctor  saw  that 
he  had  before  him  a  very  formidable  case  of  trachetis,  with 
intense  spasm  of  the  glottis  ;  and  as  the  patient  had  only 
just  recovered  from  a  serious  illness,  he  was  inclined  to  fear 
this  one  would  turn  out  to  be  rather  unmanageable.  Aconite 
and  Belladonna  were  given  in  succession,  but  equally  without 
benefit ;  the  distress  increasing  with  an  increasing  dyspnoea, 
the  lips  were  blue  and  the  hands  also,  the  arms  being  rigid 
up  to  the  elbow.  In  this  emergency  Dr.  Harvey  was  called 
in,  when  Bromine  was  given  by  inhalation  and  Aconite  every 
fifteen  minutes,  but  the   patient  got  rapidly   worse,   and  the 


SPASM    OF    THE    GLOTTIS.  97 

medical  attendants  were  in  fear  of  seeing  her  perish  of 
asphyxia  before  their  eyes  ;  the  power  of  deglutition  had 
almost  ceased — hands  and  feet  were  cold.  In  this  desperate 
strait,  Stokes  happily  thought  of  Gelsemium,  of  which  a 
portion  of  a  drop  of  the  mother-tincture  was  at  once  given. 
The  effect  was  something  akin  to  the  marvellous.  "  Scarcely 
had  the  fluid  passed  over  the  tongue  when  we  saw  the 
inspirations  lengthen,  and  felt  the  hands  relax  from  their 
rigidity.  The  countenance  began  at  once  to  brighten,  the 
hands  soon  regained  a  more  natural  appearance,  and  the 
whole  bearing  of  the  patient  was  easier  and  happier.  In  a 
quarter  of  an  hour  we  gave  the  remains  of  the  dose,  and  so 
rapid  was  the  improvement  that  in  another  quarter  of  an 
hour  we  were  able  to  go  home  to  bed.  I  had  been  with  her 
four  hours,  but  had  I  thought  earlier  of  using  Gelsemium  I 
need  not  have  had  an  anxious-  and  broken  night."  A  rapid 
cure  followed,  though  the  larynx  continued  intensely  tender 
and  deglutition  difficult  for  a  week. 

The  second  case  was  a  young  lady  thirteen  years  of  age, 
prone  to  laryngeal  disease.  "  I  went  at  once  and  saw  this 
child  in  a  state  of  intense  distress.  The  old  nurse  was  try- 
ing to  hold  her  on  her  lap,  but  she  was  dashing  herself  about 
in  a  frenzy  of  fright  and  agony.  The  face  was  purple,  the 
eyes  protruding,  the  larynx  was  spasmodically  jerked  up  and 
down,  and  suffocation  seemed  imminent.  I  thought  at  once 
of  Gelsemium  and  how  it  had  served  me  before.  So  mixing 
two  drops  of  mother  tincture  in  four  teaspoonfuls  of  water, 
I  gave  her  one  teaspoon ful  of  the  mixture,  and  bade  the 
mother  watch  the  effect.  In  five  minutes  there  seemed  to 
be  a  slight  improvement,  inasmuch  as  the  movements  were 
less  frantic  and  violent.  A  second  dose  was  given,  and  in 
five  minutes  more  a  visible  change  had  come  on.  The 
patient  could  now  take  breath  more  easily,  sat  still  on  the 
nurse's  knee,  and  the  acute  and  strident  sound  of  the  inspira- 
tion had  given  way.  The  mother  watched  and  wondered  ;  but 
we  gave  another  dose  at  the  expiry  of  five  minutes  after  the 
last,    and    by   that  time    all    distress    had    passed    away.     I 


gB  SPASM     OF    THE    GLOTTIS. 

remained  while  the  patient  was  being  put  to  bed,  and  was  in 
the  house  half  an  hour  in  all.  The  larynx  remained  very 
tender  for  a  week,  but  I  continued  to  treat  the  case  with 
Gelseminum  and  Mercurius,  and  kept  her  in  one  room  all 
the  time." 

Iodium  is  not  merely  homoeopathic  to  the  acute  attack, 
but  it  is  also  one  of  the  deeper-acting  remedies  which  must 
be  given  if  the  cause  is  to  be  reached.  We  owe  this  remedy 
dy  to  Baehr,  who  thus  introduces  it  to  the  notice  of  our 
school  :  "  Iodium  is  doubtless  a  very  excellent  simile,  and 
is  likewise  adapted  to  all  three  above-named  causal  morbid 
conditions.  (These  conditions  are  rachitis,  a  deficient  invo- 
lution or  hypertrophy  of  the  thymus  gland,  and  swelling  of 
the  bronchial  glands.)  With  this  remedy  alone,  given  every 
other  day  at  the  fourth  or  sixth  attenuation  for  four  to  eight 
weeks  ;  we  have  cured  five  undoubted  cases  of  spasm  of  the 
glottis,  which  evidenced  their  malignant  nature  by  the  fact 
that  every  subsequent  attack  was  more  violent  than  the  pre- 
ceding one.  The  patients  were  children  not  yet  a  year  old, 
but  only  one  of  them  showed  an  enlargement  of  the  thymus 
gland.  Supported  by  such  striking  curative  results,  we  can- 
not be  accused  of  hazardous  speculation  if  we  prefer  this 
remedy  to  all  others,  as  long  as  the  general  organism  has 
not  become  too  much  reduced."  The  following  are  the 
indications  usually  given  for  this  remedy,  though  it  must  be 
confessed  that  they  are  somewhat  vague:  Rachitic  children  ; 
swelling  of  the  bronchial  glands;  tightness  and  constriction 
about  the  larynx  ;  soreness,  hoarse  voice,  etc.;  enlarged  glands 
may  even  cause  paralysis  of  the  laryngeal,  tracheal  and  bron- 
chial nerves.  Dunham  gives  the  following  indications  :  en- 
largement and  induration  of  the  glands,  cervical  and  mesen- 
teric; absence  of  appetite;  utter  indifference  to  food; 
scanty,  high-colored  urine  ;  clayey  evacuations  ;  emaciation  ; 
yellow  skin  :  action  of  the  heart  feeble,  and  much  increased 
by  motion.  Guided  by  these  indications,  Dunham  reports 
the  following  striking  case  : 

"  The  case  for  which  I  recently  prescribed  Iodine  was  that 


SPASM    OF    THE    GLOTTIS.  99 

of  an  infant  of  ten  months,  whose  mother  states  that,  early 
in  life,  the  child  had  marasmus,  and  was  very  low.  Recov- 
ering from  this,  under  homoeopathic  treatment,  she  had  a 
wheezing  or  rattling  in  the  chest,  which  gradually  increased 
for  two  months,  until  she  could  be  heard  breathing  at  a 
great  distance.  She  coughed  for  a  week  or  two,  then  the 
cough  ceased.  About  August  1st  she  began  to  have  spasms 
of  breathlessness,  occurring  usually  at  night,  when  asleep, 
and  during  the  day  while  asleep,  and  seeming  as  if  they 
would  take  her  life.  I  could  not  distinguish  a  special  indi- 
cation for  any  remedy  in  any  peculiarity  of  these  spasms, 
and  otherwise  the  child  seemed  perfectly  well.  I  therefore 
adopted  a  plan  which  has  often  helped  me  in  blind  cases. 
I  went  back  on  the  line  of  development  of  the  child's  sym- 
toms,  until  I  found  symptoms  which' furnished  an  indication 
and  then  prescribed  as  though  these  symptoms  were  now 
present.  Adopting  this  plan,  it  may  be  remembered  I, 
years  ago,  prescribed  for  a  deaf  young  man  of  seventeen 
years,  Mezereum,  which  corresponded  to  the  milk  crust,  the 
suppression  of  which,  twelve  years  before,  had  been  immedi- 
ately followed  by  the  deafness.  I  prescribed  just  as  though 
the  milk  crust  was  actually  present,  and  the  deafness  was 
speedily  and  permanently  cured.  Acting  on  this  plan,  I 
recalled  the  marasmus  which  the  child  had  had,  and  the 
symptoms  of  which,  as  described  to  me,  indicated  Iodium. 
This  remedy  was  certainly  not  contra-indicated  by  the  affec- 
tion of  the  glottis,  which  was,  I  think,  a  partial  paralysis  and 
not  spasm.  The  attacks  of  dyspnoea  gradually  ceased,  and 
within  ten  days  had  disappeared.  The  potency  used  was 
the  two  hundredth. 

Dr.  Dunham  says  that  the  breathing  furnished  no  particular 
indication  for  Iodine  more  than  for  Spongia  or  Sambucus,  so 
that  we  must  fall  back  on  the  general  indications  already 
given.  Personally,  I  have  had  no  experience  with  this 
remedy. 

Chlorine  is,  according  to  Searle,  the  most  prominent  of  the 
remedies  for  spasm  of  the  glottis,  and  he  thinks  that  a  large 


I0O  SPASM     OF    THE    GLOTTIS. 

majority  of  instances  of  simple  idiopathic  spasmus  glottidis 
may  be  expected  to  yield  to  it.  Still,  he  candidly  admits 
that  the  symptoms  produced  by  it  are  those  which  occur  in 
every  case  <>f  spasm  of  the  glottis,  to  a  greater  or  less  extent, 
adding  that  "the  characteristic  and  distinctive  symptoms  of 
the  drug  have  never  been  evolved."  The  attacks  come  on 
suddenly  and  without  warning,  the  child  takes  a  long  inspira- 
tion with  a  slight  crowing  noise,  but  he  cannot  make  the 
expiration  ;  inspiration,  when  again  made,  was  found  easy 
enough,  but  attended  by  a  slight  crowing  sound,  expiration 
again  impossible.  The  face  was  livid,  with  bluencss  of  the 
mouth.  The  lungs  are  fearfully  distended  from  frequent 
inspiration  without  any  corresponding  exit  of  air,  and  this 
finally  results  in  more  or  less  complete  asphyxia,  with  or 
without  convulsions,  during  which  the  spasm  relaxes  and  free 
respiration  takes  place.  The  attacks  come  on  after  excite- 
ment, during  sleep,  and  they  are  most  common  from  midnight 
till  seven  A.  M. 

Dr.  Dunham,  who  introduced  Chlorine  to  our  notice,  gives 
us  the  following  instructive  cases: 

"June  24th.  A  female  infant,  seven  months  old,  well 
developed  and  large,  the  fourth  child  of  healthy  parents,  was" 
brought  to  me  with  the  following  history :  Having  been 
previously  in  perfect  health,  she  was  seized  three  weeks  ago 
with  a  spasmodic  affection  of  the  respiratory  organs.  Sud- 
denly, and  without  any  warning,  she  would  make  a  long 
inspiration,  with  a  slight  crowing  noise  ;  an  attempt  to  exhale 
would  be  made,  but  without  success ;  another  crowing 
inspiration  followed  by  a  forcible  but  ineffectual  effort  to 
exhale,  and  this  would  be  repeated  until  the  child  became 
blue  around  the  mouth,  and  sank  into  partial  unconscious- 
ness, when  free  respiration  would  take  place,  and  the  child 
would  generally  sink  into  a  deep  sleep.  Frequently  towards 
the  close  of  an  attack,  convulsive  movements  of  the  extrem- 
ities would  be  noticed,  and  once  general  spasm  occurred.  At 
first  these  attacks  came  on  only  after  some  excitement,  or 
on  the  child  being  startled.    They  frequently  occurred  during 


SPASM    OF    THE    GLOTTIS.  IOI 

sleep,  arousing  the  child  suddenly,  and  they  were  most 
frequent  from  midnight  to  7  A.  M.  Within  the  week  before 
I  saw  her,  they  had  become  very  frequent — as  many  as  30 
to  40  occurring  during  the  24  hours.  The  child  had  begun 
to  emaciate  rapidly,  had  lost  appetite,  strength  and  playful- 
ness, the  face  was  pale  and  bloated,  and  the  eyes  had  a  dull 
and  glassy  expression.  The  child  had  been  under  most 
skillful  homoeopathic  treatment  since  the  commencement  of 
the  attacks,  and  as  she  failed  to  improve,  change  of  air  was 
recommended,  and  she  was  brought  to  Newburgh.  The 
climate  failing  to  benefit  her,  the  child  was  placed  under  my 
care.  The  case  seemed  all  the  more  serious  from  the  fact 
that,  last  year,  the  parents  had  lost  an  older  child,  a  boy, 
with  the  same  affection.  In  the  fourth  week  of  the  disease, 
of  which  the  course  had  been  in  every  respect  similar  to  that 
of  the  infant  above  narrated,  convulsions  supervened,  and 
the  child  died  at  the  end  of  the  sixth  week.  This  child  was 
under  enlightened  allopathic  care.  It  may  be  interesting  to 
note  that  the  autopsy  revealed  no  malformation,  and  no 
organic  lesion  ;  simply  emaciation  and  atrophy. 

"  On  careful  examination  of  my  little  patient,  I  could 
discover  nothing  abnormal  in  the  condition  of  the  heart  or 
lungs,  and  no  sign  of  disease  that  was  not  fairly  attributed 
to  the  frequent  recurrence  of  these  spasms,  with  the  venous 
congestion  consequent  upon  them,  It  was  evidently  a  case 
of  Spasmus  Glottidis  (asthma  thymicum,  asthma  millari, 
asthma  laryngeum  infantum,  laryngismus  stridulus),  and  had 
advanced  almost  to  the  second  or  convulsive  stage  in  which 
the  prognosis  is  decidedly  unfavorable. 

"  The  remedy  which  is  recommended  before  all  others  for 
this  disease,  in  our  hand-books  and  repertories,  is  Sambucus. 
The  symptoms  on  which  this  recommendation  is  based  are 
the  following:  'Slumber  with  half-open  eyes  and  mouth;  on 
awakening  from  it  he  could  not  draw  a  breath,  and  was  com- 
pelled to  sit  up,  whereupon  respiration  was  very  hurried  with 
wheezing  in  the  chest,  as  if  he  should  suffocate  ;  he  lashed 
about  with  his  hands;  the  head  and  face  were  bloated  and 


102  SPASM    OF    THE    GLOTTIS. 

bluish;  he  was  hot  without  thirst;  weeping  at  the  approach 
of  a  paroxysm  ;  all  this  without  cough,  and  especially  at 
night  from  twelve  to  four  o'clock.'  On  comparing  this 
picture  with  the  case  under  consideration,  we  find  corre- 
spondences in  the  general  characters  of  the  affection.  The 
spasmodic  embarrassment  of  respiration,  the  absence  of  fever 
and  of  cough,  the  occurrence  of  the  paroxysms  suddenly, 
chiefly  at  night,  and  on  awaking  show  a  general  appropriate- 
ness of  Sambucus  to  spasm  of  the  larynx  and  bronchial 
tubes.  But  we  seek  in  vain  for  the  unequal  disturbance  of 
the  inspiratory  and  the  expiratory  act,  which  are  the  indi- 
vidual and  therefore  the  characteristic  peculiarity  of  the  case 
under  consideration.  And  failing  to  find  this,  we  should,  as 
a  matter  of  course,  expect  that  Sambucus  would  fail  to  cure, 
or  in  any  way  to  affect  the  case.  And  this  had  been  the 
fact.  So,  too,  of  Lachesis  and  several  other  remedies  which, 
as  well  as  Sambucus,  had  already  been  tried  before  the  case 
came  under  my  care.  In  this  very  peculiarity,  which  was 
characteristic  of  the  case,  the  similarity  of  Chlorine  was  most 
striking.  And  it  was  with  the  utmost  confidence  of  a  happy 
result  that  I  determined,  after  a  careful  examination  of  the 
case,  to  administer  Chlorine.  I  accordingly  prepared  a 
saturated  solution  of  Chlorine  gas  in  water  of  6o°  Fahrenheit, 
and  made  from  this  the  first  centesimal  dilution  in  which  the 
odor  of  the  Chlorine  could  be  faintly  perceived. 

"  Of  this,  I  ordered  twenty  drops  to  be  dissolved  in  four 
tablespoonfuls  of  water,  and  a  teaspoonful  to  be  given  to 
the  child  every  three  hours  (a  porcelain  spoon  was  used). 
I  also  directed  a  few  drops  to  be  placed  in  the  child's  mouth 
at  the  beginning  of  each  paroxysm  if  this  should  be  possible. 

"The  first  dose  was  given  at  four  P.  M.,  June  24th.  During 
the  preceding  twenty-four  hours  the  child  had  had  forty 
paroxysms.  During  the  succeeding  twenty-four  hours,  there 
occurred  but  four  paroxysms  ;  only  one  of  which  began  with 
any  severity,  and  this  one  was  instantly  arrested  midway  by 
a  few  drops  of  the  solution  placed  upon  the  child's  tongue. 
During     the    night    of    the    26th,    not    a    single    paroxysm. 


SPASM    OF    THE    GLOTTIS.  103 

Improvement  in  the  general  condition  of  the  patient  now 
became  apparent,  appetite  and  playfulness  returned,  the 
bloated  aspect  of  the  face  and  the  dulness  of  the  eye  disap- 
peared. On  the  27th,  the  paroxysms  increased  in  number 
and  severity.  On  examining  the  solution  I  found  that  it  had 
changed  in  character,  and  no  longer  contained  Chlorine.  A 
fresh  solution  was  prepared,  and  henceforward  it  was  prepared 
fresh  every  second  day.  From  this  time,  July  1st,  the  remedy 
was  continued;  a  dose  every  four  hours — when  the  spasms 
having  wholly  ceased,  and  the  child  appearing  well,  it  was 
finally  discontinued.  On  the  2d  of  July  a  slight  spasm 
occurred,  and  the  child  appeared  feverish  and  excited — with 
greenish  diarrhoea.  I  found  a  lower  incisor  pressing  strongly 
upon  the  gum,  which  was  hot  and  swollen,  and  which  I 
forthwith  lanced.  In  two  hours  the  child  had  lost  every 
trace  of  illness.  Since  that  date  she  has  continued  in  good 
health,  with  the  exception  of  some  trifling  disorder  attendant 
upon  dentition.  There  has  been  no  sign  of  a  recurrence  of 
the  spasm  of  the  glottis." 

"  Last  month  I  was  called  to  a  child  two  years  and  a  half 
old,  which  had  just  been  brought  home  from  the  country, 
and  was  supposed  to  be  at  the  point  of  death.  Five  weeks 
before,  it  had  sickened  with  scarlatina,  which,  according  to 
the  physicians  in  attendance,  had  become  complicated  by 
diphtheria,  and  this  by  inflammation  of  the  right  lung  and 
deposit  therein.  An  abscess  had  formed  and  discharged  ex- 
ternally on  the  neck,  leaving  an  ulcer  about  two  inches  long 
and  one  and  a  half  broad,  which  exposed  the  cervical  muscles 
and  showed  no  disposition  to  heal  ;  copious  and  very  offen- 
sive discharge  from  both  ears ;  the  throat  seemed  to  be  full 
of  a  thick,  yellow  matter,  very  offensive,  which  the  child 
would  occasionally  eject,  but  seemed,  for  the  most,  to  be 
unable  to  move  either  up  or  down.  Any  attempt  to  exam- 
ine the  throat,  or,  on  the  part  of  the  child,  to  open  the 
mouth  to  take  food  or  drink,  or  any  attempt  to  cough,  pro- 
duced a  fearful  spasm  of  the  glottis,  which  seemed  to  admit 
the  air  well  enough,  but  to  prevent  its  exit,  and  which  lasted 


104  SPASM    OF    THE    GLOTTIs. 

until  the  child  became  Livid  and  sank  exhausted,  and  this 
constituted,  in  the  opinion  of  my  predecessors,  the  insupera- 
ble obstacle  to  the  child's  recovery.  The  spasm  prevented 
its  tasting  food.  No  food  had  been  taken  for  a  week,  and 
very  little  during  the  entire  illness.  The  child  was  now 
very  feeble  and  greatly  emaciated.  Its  death  had  been 
hourly  looked  for  by  the  doctors. 

"  I  prepared  immediately  some  Cldoriiic  water,  diluted, 
until  the  gas  was  just  perceptible,  and  gave  it  to  the  child. 
He  took  a  mouthful  and  began  to  choke  with  the  spasm  ;  I 
immediately  placed  near  his  face  a  handkerchief  wet  with 
strong  Chlorine  water,  so  that  he  might  inhale  the  gas.  The 
spasm  ceased  instantly  and  he  swallowed.  I  left  orders  for 
a  similar  procedure  whenever,  from  any  cause,  whether 
coughing  or  swallowing,  the  spasm  should  be  induced.  It 
never  failed  to  arrest  the  spasmodic  action  and  enable  the 
child  to  swallow,  or  to  eject  the  matter  from  the  throat.  A 
number  of  days  elapsed  before  the  child  could  make  an  ar- 
ticulate sound,  or  any  sound.  The  doctors  had  thought  the 
diphtheria  had  induced  paralysis  of  some  of  the  pharyngeal 
muscles,  and  perhaps  others,  and  hence  the  spasm  in  associ- 
ate and  neighboring  muscles ;  and  it  may  be  so.  They 
regarded  the  spasm  as  an  insuperable  barrier  to  recovery. 
It  was  evident  to  every  attendant  that  the  Chlorine  relaxed 
the  spasm  and  enabled  the  child  to  swallow.  His  subse- 
quent improvement  was  uniform  and  rapid  under  Carbo 
vegetabilis  200." 

Cuprum  is,  according  to  Baehr,  particularly  appropriate  if, 
during  the  local  spasm,  general  convulsions  have  supervened 
and  the  child  has  become  very  much  prostrated,  and  Hughes 
remarks  that  whereas  Belladonna  should  be  given  where 
there  is  arterial  excitement  and  cerebral  congestion,  "Cuprum 
should  be  given  where  these  symptoms  are  absent  " — that  is, 
when  the  morbid  state  is  a  pure  neurosis.  Farrington  thinks 
Cuprum  well  adapted  to  cases  which  have  advanced  to  the 
convulsive  stage,  and  Jahr  advises  that  if  the  spasm  of  the 
glottis  sets  in  in  company  with  other  spasmodic   symptoms 


SPASM     OF    THE    GLOTTIS.  105 

to  give  "  above  all  Cuprum,"  and  I  have  certainly  never  seen 
any  good  effects  from  this  remedy  save  under  these  circum- 
stances. Duncan,  too,  tersely  says"  Cuprum  is  the  remedy." 
Cuprum  is  indicated  by  short,  panting,  whistling  breathing, 
with  gurgling  down  the  oesophagus,  and  on  attempting  to 
take  a  deep  breath  there  is  a  dyspnoea,  with  stridulous 
inspiration.  This  local,  morbid  state  is  accompanied  by 
general  convulsions,  the  body  being  stiff  with  spasmodic 
twitching  and  clenched  thumbs.  The  face  and  lips  are  both 
alike  blue,  and  the  face  is  sometimes  covered  with  cold 
sweat.  The  paroxysms  come  on  suddenly  and  cease  sud- 
denly, after  fright  of  mother  or  child.  Searle  calls  attention 
to  cold  perspiration  at  night  as  being  a  kind  of  key  note, 
and  Baehr  says  that  among  the  symptoms  indicating  the 
remedy  one  is  particularly  noticeable — vomiting  after  the 
attack. 

"  A  delicate  girl,  nine  months  old,  had  for  several  days 
suffered  with  a  cough,  spasmodic  and  more  violent  during 
the  night,  peevishness,  no  fever,  quick,  difficult  breathing, 
drawing  in  of  the  muscles  of  the  right  and  left  hypochon- 
driac regions  during  inspiration,  percussion  normal,  rattling 
of  mucus  far  down,  little  appetite,  tongue  with  whitish  coat- 
ing, daily,  one  or  two  thin,  sometimes  watery,  sometimes 
greenish  stools.  Ipec.  9  every  two  hours.  While  asleep  the 
child  suddenly  began  to  breathe  more  quickly,  and  with 
greater  difficulty  ;  grew  restless  and  tossed  about  in  bed  ; 
face  bluish  ;  eyes  wide  open  ;  larynx  drawn  upward  ;  she 
braced  herself  against  the  bed  with  her  hands  ;  perceptible 
cramps  in  the  respiratory  muscles  ;  predominant  abdominal 
respiration ;  the  cough,  which  was  very  exhausting,  was 
attended  by  a  very  peculiar  hollow,  somewhat  hoarse  sound; 
at  times,  also,  metallic-sounding,  piping,  short  coughs;  hands 
cold  ;  cold  sweat  on  forehead  ;  spasmodic,  small,  very 
frequent  pulse.  The  attack  lasted  five  to  six  minutes  ;  after- 
ward the  child  sank  back  exhausted,  coughed  a  few  times 
loosely  and  easily,  and  fell  into  a  stupefied  sleep.  She  had 
five   or   six   of  these  attacks  for  several  consecutive  nights. 


Ic/>  SPASM    OF    THE    GLOTTIS. 

but  of  longer  duration,  [pec.  every  two  hours.  The  next 
day  only  one  attack,  which  lasted  only  three  to  four  minutes. 
During  the  day  great  debility,  little  appetite  ;  cough  easy 
and  loose,  and  even  none  at  all  for  four  or  five  hours  at 
a  time  ;  respiration  normal ;  two  somewhat  slimy,  but 
otherwise  healthy  stools.  The  next  night  two  rather  lighter 
attacks,  but  next  day  still  greater  debility.  Cuprum  9  in 
Small,  lad.,  one  powder  ;  if  necessary  another  during  the 
night.  At  midnight  a  very  light  attack,  lasting  only  two  to 
three  minutes.  The  next  day  general  health  and  appetite 
better.  One  dose  Cuprum.  No  more  attacks  and  soon 
restored  to  perfect  health.     (Dr.  Hirsch.) 

'A  very  delicate  child,  about  one  year  old,  had,  since  six 
nights,  very  violent  attacks  of  spasm  of  the  glottis  without 
any  coughs,  either  during  the  attacks  or  at  other  times  ;  they 
lasted  five  to  ten  minutes.  Cuprum  9,  three  doses,  one  every 
evening,  relieved  the  patient  entirely."     (Dr.  Hirsch.) 

I  have  never  seen  any  good  results  from  Cuprum  when 
given  below  the  12th  centesimal  dilution,  and  have  generally 
given  the  Hahnemannian  30th  with  almost  unvarying  success, 
but  I  must  add  that,  in  my  experience,  cases  in  which 
Cuprum  is  indicated  are  not  very  common. 

Hughes  says  that  in  the  paralytic  variety  Ignatia  seems  to 
be  the  remedy  most  homoeopathic  to  the  paroxysm,  but 
Baehr,  after  stating  that  this  remedy  is  very  much  praised  if 
the  children  suddenly  lose  their  breath,  which  may  be  the 
lowest  degree  of  spasm  of  the  glottis,  adds  that  "  whether 
it  will  prove  a  proper  remedy  for  spasm  of  the  glottis  has 
not  yet  been  verified."  Personally,  I  have  not  found  it 
useful  in  idiopathic  cases,  though  it  has  helped  when  the 
spasm  was  a  mere  incident  in  other  diseases,  say  catarrhal 
croup  or  whooping  cough.  Of  the  symptoms  one  of  the 
most  characteristic  is  the  difficulty  of  inspiration  while 
expiration  is  easy,  and  this  difficulty  is  suddenly  experienced 
at  midnight.  All  kinds  of  respiration  alternate  during  sleep, 
short  and  slow,  deep  and  light,  intermitting  and  snoring. 
Also  a  sudden  (not  tickling)  interruption  of  breathing  in  the 


SPASM     OF    THE    GLOTTIS.  107 

upper  part  of  the  trachea,  which  irresistibly  provokes  a  short, 
forcible  cough  in  the  evening.  I  have  always  used  the  12th 
centesimal  dilution,  though  possibly  the  6th  might  have 
been  still  more  effective. 

LacJiesis  has  been  successfully  used,  though  Jahr  says  it 
has  never  afforded  him  much  help  in  this  disease,  while 
Drysdale  says  that  it  is  one  of  the  two  medicines  which  he 
has  found,  on  the  whole,  most  useful — arsenicum  being  the 
other.  Personally,  I  am  of  opinion  that,  like  Ignatia,  this 
remedy  is  not  indicated  in  idiopathic  spasm  of  the  glottis, 
but  that  it  is  often  indicated  when  a  partial,  imperfectly- 
developed  form  of  this  morbid  state  supervenes  on  inflam- 
matory affections  of  the  throat. 

Lachesis  is  indicated  when  the  paroxysms  occur  during 
sleep ;  the  child,  as  it  were,  sleeps  into  an  attack,  and  is 
roused  gasping  for  breath.  Or  the  paroxysms  may  recur 
after  each  nap.  There  is  great  sensitiveness  of  the  larynx 
and  trachea  to  the  touch  ;  sense  of  constriction  of  the  larynx, 
attended  with  dryness  of  the  whole  throat  and  mouth.  Dr. 
S.  C.  Knickerbocker  reports  an  excellent  case  in  which  the 
attacks  were  becoming  more  frequent  and  more  severe, 
which  was  radically  cured  with  two  prescriptions  of  Lachesis 
200.  The  attacks  consisted  of  a  sense  of  constriction  of  the 
larynx,  attended  with  dryness  of  the  whole  throat  and 
mouth — the  attacks  invariably  occurred  after  sleeping — the 
"  key-note  "  of  Lachesis. 

"  Plumbum  is  very  closely  related  to  Cuprum  in  every 
respect,  except  that  the  general  strength  is  still  more 
reduced.  The  symptoms  of  a  spasmodic  closing  of  the  rima 
glottidis  are  more  distinctly  marked  in  the  pathogenesis  of 
this  drug  than  in  that  of  any  other.  We  are  amazed  that 
Plumbum  shoulJ  not  yet  have  been  recommended  for  this 
disease,  which,  however,  can  only  be  cured  by  remedies  which 
exert  a  deeply-penetrating,  long-lasting  influence  over  the 
whole  organism."  (B?ehr.)  Kane,  too,  recommends  it  the 
last  of  the  few  but  well-chosen  remedies  with  which  he 
combats  spasm  of  the    glottis,  but  Searle,  after  remarking 


I08  SPASM     OF    THE    GLOTTIS. 

tliat  it  has  the  mucous  rile  with  sudden  difficulty  of  breathing 
and  asphyxia,  adds,  "but   I   do  not  know  that  it  has  ever 

been  tried  as  a  remedy  for  this  disease."  Here,  too,  I  have 
had  no  experience,  for  I  have  never  met  with  a  case  in  which 
it  seemed  to  he  indicated. 

Dr.  Alphonse  Teste  considers  that  Corallia  rubra  and 
Opium  are  "heroic  agents  against  this  disease,"  and  as  to 
the  dose,  he  adds,  "  I  prescribe  Corallia  at  the  thirtieth  and 
Opium  at  the  third  dilution,  a  teaspoonful  every  two  hours 
during  the  period  of  invasion  ;  every  ten  minutes  during  the 
exacerbations,  and  at  intervals  gradually  increased  when 
these  are  passed.  The  last-mentioned  remedy  is  to  be  given 
every  six  hours,  for  a  day  or  two  after  the  resolution  of  the 
last  attack."  As  spasm  of  the  glottis  frequently  accompanies 
rachitis,  Dr.  Richard  Hughes  remarks  that  "  the  Corallia  rubra 
so  lauded  by  Teste,  in  its  treatment  may,  from  its  calcareous 
nature,  be  suitable  to  these  diathetic  conditions  as  well  as  to 
the  laryngeal  spasms."  Searle  thinks  that  the  Corallia  rubra 
may  be  serviceable  in  cases  which  it  is  difficult  to  distinguish 
from  whooping  cough,  and  Farrington  recommends  Opium 
"  especially  after  a  fright,"  but  I  have  never  seen  any  benefit 
from  the  use  of  Opium  in  this  disease. 

The  above  are  the  leading  remedies,  but  occupying  a 
secondary  rank  are  Zincum,  Bromine,  Nux  vomica,  Pulsatilla, 
Veratrum  album,  Lauroccasus,  Spongia  and  Sulphur. 

Dr.  Pemerl,  of  Munich,  points  out  that  "when  the  spread 
of  the  spasms  of  the  glottis  to  other  respiratory  muscles,  to 
the  tongue,  to  the  upper  and  lower  extremities,  announces 
the  transit  to  general  convulsions,  Moschus  does  not  suffice 
any  more,  and  we  prefer  the  first  trituration  of  Zinc-oxyd., 
either  alone  or  in  alternation  with  Moschus.  Bromine  has 
spasmodic  closure  of  the  glottis  and  constriction  in  the 
larynx,  with  a  wheezing  and  rattling  in  the  larynx;  gasping 
and  snuffling  for  breath  ;  cannot  inspire  deep  enough  ;  the 
head  and  face  arc  hot.  Nux  vomica  is  recommended  by 
Kane  and  Duncan  for  reflected  irritation  from  derangement 
of  the  digestive  organs.      Pulsatilla  is  said  by  Laurie  to  be 


SPASM    OF    THE    GLOTTIS.  IO9 

often  found  successful  in  cases  in  which  Moschus  appears 
capable  only  of  effecting  a  limited  degree  of  improvement, 
but  the  present  writer  has  never  seen  any  good  effect  from 
it,  and  it  is  doubtful  whether  it  has  ever  been  successfully 
used  in  unquestionable  cases  of  spasm  of  the  glottis.  Vera- 
trum  album  is  recommended  by  Jahr  if  spasm  o  the  glottis 
sets  in  in  company  with  other  spasmodic  symptoms  ;  Bsehr 
advises  it,  together  with  Arsenicum  album,  if  the  disease 
attacks  feeble  children  with  marked  symptoms  of  anaemia, 
and  the  writer  has  used  it  successfully,  in  the  12th  centesimal 
dilution,  when  the  patient  was  already  cold  and  pale,  with 
contracted  pupils  and  protruded  eyes.  Laurocerasus  when 
the  child  is  pale  and  blue,  with  spasmodic  constriction  of  the 
throat  and  congestion  of  the  chest  ;  Farrington  recommends 
it  when  the  head  is  affected,  which  is  rarely  the  case.  Spongia 
is  indicated  when  the  child  starts  from  sleep  with  constriction 
of  the  larynx,  whistling  respiration,  the  patient  breathes  with 
the  head  bent  backwards  ;  this  remedy  may  be  used  against 
the  constitutional  disease  as  well  as  the  laryngeal  spasm. 
Chamomilla  is  recommended  for  a  sensation  of  oppression 
and  slight  constriction  in  the  region  of  the  larynx  ;  constric- 
tion of  the  larynx  with  dyspnoea ;  hot  sweat  on  the  head  and 
face,  especially  during  sleep.  The  child  becomes  stiff  and 
bends  backwards,  kicks  with  his  feet  when  carried,  screams 
and  throws  everything  off ;  staring  eyes,  the  child  reaches 
and  grasps  for  something,  draws  the  mouth  back  and  forth. 
The  patient  is  peevish  and  irritable  ;  cries  for  things  and 
pushes  them  away  when  given  to  him  ;  worse  from  anger  or 
other  violent  emotions,  from  dentition  and  from  exposure  to 
cold  winds.  This  remedy  is  not  suited  to  well-developed 
cases,  though  I  have  seen  it  do  good  in  such  cases  as  the 
above.  Of  Sulphur,  Baehr  says  that  it  "  may  deserve  atten- 
tion, although  we  shall  take  the  liberty  of  doubting  the 
homoeopathicity  of  its  asthmatic  symptoms  to  spasm  of  the 
glottis  until  the  fact  has  been  corroborated  by  experience," 
but  though  I  have  never  seen  a  case  in  which  Sulphur  would 
help  during  the  acute  attack,  I  have  for  many  years  given  it 


110  SPASM    OF    THE    GLOTTIS. 

in  the  30th  dilution  to  prevent  a  recurrence  of  the  dreaded 
disease,  thus  following  an  invaluable  hint  of  good  old  Jahr's. 
"  In  more  than  one  case,  however,  I  have  radically  removed 
a  disposition  to  the  return  of  the  spasm  by  means  of  a  dose 
of  Sulphur." 

The  remedy  indicated  by  the  ensemble  of  the  symptoms 
should  be  given  at  the  time  of  the  attack  as  well  as  during 
the  interval,  but  it  is  evident  that,  as  the  paroxysm  lasts  but 
a  very  short  time,  that  it  is  not  always  possible  to  give  the 
medicine.  The  same  remark  applies  to  very  many  of  the 
external  applications  recommended  by  various  authors,  for, 
in  the  vast  majority  of  cases,  the  little  patient  is  out  of  the 
paroxysm  before  the  machinery  is  in  motion,  and  in  the 
matter  of  treatment,  the  writer  relies  very  much  on  what  is 
done  (fu ring  the  interval. 

All  external  causes  which  may  have  the  effect  of  irritating 
or  exciting  the  nervous  system  should  be  carefully  avoided, 
and  moral  causes  are  just  as  important  as  physical.  There 
should  be  no  sudden  surprises,  cither  playful  or  otherwise. 
The  temper  should  be  irritated  as  little  as  may  be.  All 
muscular  effort  should  be  carefully  avoided,  and  Copland 
gives  the  excellent  advice  to  avoid  straining  at  stool. 

During  the  attack  the  patient  should  be  placed  in  an 
upright  attitude,  so  as  to  place  the  larynx  in  the  easiest 
position  possible,  and  all  tight  clothing  should  be  promptly 
removed — or  rather,  tight  clothing  should  never  be  put  on 
children  subject  to  spasm  of  the  glottis.  Vogel  thus  describes 
a  simple  operation  much  in  vogue  in  Germany,  which  I  have 
used  with  marked  benefit  :  "  In  the  instances  where  I 
happened  to  be  present  at  the  paroxysms,  I  introduced  the 
index-finger  into  the  mouth,  carried  it  to  the  posterior 
pharyngeal  wall,  elevated  the  spiglottis,  and  then  touched 
the  chordae  vocales,  by  which  marked  acts  of  choking  were 
at  once  induced,  and  then  the  well-known  whistling  inspira- 
tion followed.  Lay  people,  of  course,  are  unable  to  execute 
these  manoeuvres,  and  I  therefore  content  myself  by  showing 
them  how  retching  may  invariably  be  induced  by  pressure 


SPASM    OF    THE    GLOTTIS.  1  1 1 

upon  the  root  of  the  tongue.  The  shock  produced  by 
inducing  this  act  of  retching  is  the  only  harmless  remedy 
which  will  cut  short  the  paroxysm."  Dr.  Morell  Mackenzie's 
advice  to  "  slap  the  patient  on  the  back  "  should  be  carefully 
shunned.  The  same  writer  advises  the  dashing  of  cold 
water  on  the  face,  though  Vogel  says  that  he  has  seen  no 
decided  effects  from  cold  affusions  as  well  as  from  the  forci- 
ble to-and-fro  swinging  in  the  air,  so  much  in  vogue  with 
nurses.  Steffen  advises  the  full  warm  bath  of  from  900  to 
950  Fahr.  combined  with  cold  affusions  over  the  head  and 
neck,  if  the  cyanosis  assumes  a  high  grade,  consciousness  is 
lost  and  general  convulsive  attacks  set  in,  but  the  one 
objection  to  these  procedures  is  the  time  involved  in  carry- 
ing them  out.  Romberg  gives  us  the  excellent  advice  to 
warm  the  prcecordia  with  hot  napkins  during  the  attack. 

Should  Chloroform  be  used  during  the  paroxysm  ?  Sir 
James  Simpson  proposed  its  use  in  this  disease,  and  Dr. 
Charles  West  and  other  excellent  English  practitioners  say 
that  they  have  always  secured  prompt  results  without  any 
ill  effect  whatever  ;  Dr.  Duncan  of  Chicago,  an  excellent 
homoeopathic  authority,  endorses  this  recommendation. 
Morell  Mackenzie  says  that  "  the  inhalation  of  Chloroform  is 
a  very  valuable  remedy,  but  of.  course,  it  must  be  used  with 
great  care."  Steffen,  too,  advises  it  to  be  used  with  great 
caution,  and  Dr.  G.  B.  Wood  advises  the  practitioner  to 
bear  in  mind  the  hazardous  character  of  this  remedy.  Vogel 
remarks  that  "  it  is  too  dangerous  an  agent  to  be  left  to  the 
use  of  the  lay  attendant,"  and  of  course  the  physician  could 
rarely  be  present  to  administer  it  during  the  paroxysms,  and 
for  this  reason  as  well  as  for  that  given  by  Romberg,  I  am 
disinclined  to  use  this  agent.  Romberg  says,  "  it  has  been 
proposed  to  give  Chloroform,  but  its  effects  upon  the  brain 
under  such  circumstances  would  probably  render  it  unsafe.'' 

Should  tracheotomy  be  employed  as  a  last  resort  ?  Mar- 
shall Hall,  together  with  Wunderlich  and  other  excellent 
German  authorities,  recommend  it  in  the  last  emergency, 
when  suffocation  is  taking  place,  and  one  of  the  latest  and 


112  SPASM    OF    THE    GLOT1 

best  of  the  English  writers  strongly  advises  it.  "  If  the 
child  appears  to  be  sinking  from  the  apncea,  the  trachea 
must,  of  course,  be  opened,  and  artificial  respiration  resorted 
to.  Indeed,  this  should  even  be  adopted  by  the  practitioner, 
should  he  arrive  shortly  after  the  apparent  extinction  of 
life."  But  Steffen,  a  still  higher  authority  in  this  particular 
disease,  remarks  that,  "aside  from  the  fact  that,  unless  the 
patient  happens  to  be  in  an  hospital,  this  operation  cannot 
always  be  performed  quickly  enough,  I  have  never  yet 
learned  of  any  favorable  result  that  has  followed  in  spasm  of 
the  glottis,"  while  Vogel  says  that  "  tracheotomy,  which  has 
been  suggested  as  a  dernier  ressort,  with  which  to  save  the 
life  of  the  child,  can  never  be  performed,  on  account  of 
want  of  time."  Partial  as  are  the  French  to  tracheotomy, 
they  have  never,  so  far  as  I  know,  recommended  it  in  this 
disease,  and  to  me  the  reasoning  of  Romberg  is  perfectly 
conclusive,  "  nobody  would  attempt  tracheotomy  at  the 
beginning  of  the  attack,  and  if  postponed  too  long  no 
benefit  can  be  expected  from  it." 

Vogel,  Steffen,  and  all  the  great  German  writers  on  this 
disease,  condemn  the  lancing  of  the  gums,  and  Romberg's 
dictum  may  be  taken  as  a  fair  specimen  of  their  reasoning  : 
"  Scarification  of  the  gums,  in  England  considered  a 
panacea,  has  not  met  with  much  countenance  in  Germany, 
as  the  excitement  produced  by  the  operation  in  the  child 
outweighs  the  possible  advantages  of  the  operation."  On 
the  other  hand,  almost  all  the  British  and  American  writers 
approve  of  the  operation,  and  we  have  seen  that  it  was 
performed  with  success  by  Dr.  Carroll  Dunham,  one  of  the 
strictest  of  Hahnemannians.  I  have  never  performed  the 
operation,  simply  because  I  have  not  yet  met  with  a  case  in 
which  it  was  indicated. 

During  the  intervals  of  the  paroxysms,  and  still  more 
during  the  paroxysm  itself,  there  should  be  a  good,  long 
interval  between  the  feeding  hours  of  the  child,  and  during 
the  continuance  of  the  disease  the  infant  must  not  be  weaned, 
and  I  have  heard  of  more  than  one  death  from  ignorance  or 


SPASM    OF    THE    GLOTTIS.  113 

neglect  of  this  simple  and  almost  self-evident  rule.  Vogel 
advises  that  the  child  be  kept  as  long  as  possible  at  the 
mother's  breast,  at  least  until  it  has  cut  the  first  six  incisors. 
,l  If  the  fit  comes  on  during  sucking,  either  from  the  leather 
teat  of  the  bottle  or  whilst  the  child  is  at  the  breast,  it  must 
be  fed  as  Flesch  insists,  with  a  very  small  teaspoon,  no  matter 
how  difficult  at  first  it  may  be  to  get  nourishment  taken  in  this 
way."  (Morell  Mackenzie.)  No  food  should  be  given  soon 
after  a  paroxysm,  for  a  second  paroxysm  may  result  from 
the  mere  act  of  swallowing,  especially  if  particles  of  food 
enter  the  larynx.  To  children  five  or  six  months  old  I  give 
beef  tea,  not  essence  of  beef,  but  a  weak  preparation  made 
by  boiling  finely  minced  beef  with  a  considerable  quantity 
of  water,  straining  it  through  fine  muslin  or  blotting  paper, 
and  I  have  seen  good  results  from  the  addition  of  a  soft- 
boiled  egg  to  the  diet.  If  the  malady  is  complicated  with 
rachitis,  no  farinaceous  food  whatever  should  be  given  ;  such 
patients  should  be  fed  on  meat  and  milk  till  they  are  at  least 
seven  years  of  age.  Steffen  advises  the  administration  of 
Hungarian  wine,  or  good,  French  red  wine. 

A  child  subject  to  spasm  of  the  glottis  should  never 
be  disturbed  during  sleep,  as,  in  many  cases,  the  excite- 
ment of  awakening  brings  on  a  paroxysm.  Steffen  thinks 
that  children  should  not  be  kept  warm  in  bed,  and,  in  oppo- 
position  to  Elsasser,  he  asserts  that  lying  down  is  no  sort  of 
disadvantage  to  children  with  craniotabes. 

I  have  found  the  cold  sponging  of  the  chest  advocated  by 
Dr.  Richard  Hughes  more  effective  than  the  daily  luke-warm 
baths  of.  Steffen,  and  as  the  child  gets  older  I  recommend 
free  sponging  of  the  entire  body  with  cold  water  every 
morning. 

To  patients  living  in  a  city  or  large  town,  great  benefit 
accrues  from  removal  to  the  fresh,  pure  air  of  the  country, 
and  if  the  case  is  at  all  severe  the  patient  should  be  at  once 
removed.  Still,  as  Vogel  remarks,  residence  in  the  country 
by  no  means  supplies  a  positive  guarantee  against  the 
appearance    of    the    spasms,  and    some    of   my  worst    cases 


114  SPASM    OF    THE    OLOTTIS. 

occurred  in  children  who  had  been  all  their  lives  in  the 
country  Wherever  the  patient  is  the  rooms  should  be 
carefully  and  systematically  ventilated,  and  Robertson  recom- 
mends the  (\cc  exposure  of  the  infant  out  of  doors  for  many 
hours  daily,  to  a  dry,  cold  atmosphere,  and  if  the  air  be  dry  the 
colder  the  better.  Dr.  Marshall  Hall  says  that  the  curative 
influence  of  change  of  air,  and  especially  of. the  sea-breezes, 
is  not  less  marked  in  this  affection  than  in  whooping  cough. 

Aphorisms. 

i.  Spasm  of  the  glottis  is  a  constriction  of  the  muscles 
which  narrow  the  glottis,  accompanied  by  crowing  inspira- 
tions, commencing  suddenly,  lasting  a  very  short  time,  and 
ceasing  suddenly. 

2.  General  convulsions  and  "  carpo-pedal "  spasms  mark 
the  advanced  stage  of  the  disease. 

3.  Spasm  of  the  glottis  may  depend  upon  an  irritated 
disease  of  the  brain,  and  also  upon  the  scrofulous  and  rachitic 
constitutions — though  its  connection  with  rachitis  is  less 
clear  than  its  connection  with  scrofula. 

4.  The  disease  is  most  prevalent  in  northern  countries  and 
during  the  Winter  season,  and  it  is  essentially  a  disease  of 
childhood,  though  adults  are  not  exempt. 

5.  Two-thirds  of  the  sufferers  from  spasm  of  the  glottis 
are  boys. 

6.  The  disease  is  not  really  hereditary,  though  several 
children  in  the  same  family  may  suffer  from  it. 

7.  Rachitis  and  spasm  of  the  glottis  often  co-exist,  but 
the  first  is  not  neccessarily  the. cause  of  the  second,  though 
rachitis  of  the  thoracic  bones  may  lead  to  the  disease  under 
consideration  by  inducing  a  deep-seated  disturbance  of  nutri- 
tion and  an  increased  irritability  of  the  nervous  system. 

8.  Weaning  favors  the  development  of  spasm  of  the  glottis, 
and  the  irritation  of  teething  may  cause  an  outbreak  of  the 
disease. 


SPASM    OF    THE    GLOTTIS.  1 15 

9.  As  the  child  grows  older  the  predisposition  to  the 
disease  declines,  and  this  depends  on  the  increased  size  of 
the  larynx  and  on  the  decreased  irritability  of  the  nervous 
system. 

10.  The  prognosis  is  more  favorable  in  girls  than  in  boys, 
and  the  older  the  patient  the  better  the  prospect  of  a 
successful  issue. 

11.  The  leading  homoeopathic  remedies  are  Sambucus, 
Aconite,  Sanguinaria,  Arsenicum  album,  Belladonna,  Gelse- 
mium,  Iodium,  Chlorine,  Cuprum  and  Ignatia  amara. 

12.  Chloroform  must  never  be  used  by  lay  hands,  and  it 
is  positively  dangerous  in  cases  depending  on  cerebral  irrita- 
tion. 

13.  The  weight  of  evidence  is  against  tracheotomy  as  a 
remedy  in  extremis. 

14.  The  patient  must  not  be  weaned  during  the  continu- 
ance of  the  disease. 


CHAPTER  V. 


Ail      I    I       C  A  T  A  R  K  II  A  I,     L  A  R  Y  N  G  1  T  I  S 


The  laryngeal  diseases  of  young  children  are  always  very 
serious,  as  from  the  small  size  and  delicacy  of  the  organ  in 
infancy,  a  comparatively  slight  inflammation  greatly  dimin- 
ishes its  calibre.  Again,  the  organ  is  absolutely  essential  to 
life,  and  but  a  slight  disturbance  of  its  healthy  function  is 
enough  to  endanger  the  very  existence  of  the  child,  especially 
in  those  not  rare  cases  in  which  there  is  a  hereditary  proclivity 
to  laryngeal  diseases.  Laryngitis  is  somewhat  frequent 
during  infancy  and  childhood,  and  I  cannot  agree  with  M. 
Bouchut  who  considers  it  "  a  disease  of  slight  importance," 
adding  that  its  termination  is  "  always  favorable."  On  the 
contrary,  it  is  frequently  a  serious  disease,  coming  on  sud- 
denly, attacking  violently,  and  requiring  skillful  treatment 
from  the  physician  and    careful  management  from  the  nurse. 

The  disease  may  be  defined  to  be  a  catarrhal  inflammation 
of  the  mucous  membrane  of  the  larynx,  sometimes  involving 
the  submucous  areolar  tissue,  giving  rise  to  hoarseness  or 
aphonia,  stridulous  and  difficult  breathing,  cough  and  pain  in 
the  larynx — especially  near  the  pomum  Adami.  Dysphagia 
is  present  in  very  severe  cases,  and  fever  is  an  almost 
invariable  accompaniment.  If  the  inflammation  is  confined 
to  the  middle  and  lower  parts  of  the  larynx  the  cough  will 
not  be  croupous,  but  if  the  epiglottis  and  rima  glottidis  are 
affected  the  cough  will  be  decidedly  croupous,  and  hence, 
many  writers  and  practitioners  speak  of  the  disease  as  being 
a  variety  of  croup.  In  reality,  as  Dr.  W.  V.  Drury  has  well 
pointed  out,  every  one,  and  especially  every  mother,  should 
know  that  there  are  five  or    six  different    diseases    with    a 


ACUTE    CATARRHAL     LARYNGITIS.  I  17 

croupal  cough — acute  laryngitis,  spasmodic  laryngitis, 
membranous    laryngitis,   dipthertic    laryngitis. 

Acute  catarrhal  laryngitis  is  often  the  result  of  repeated 
congestion  of  the  larynx,  and  it  may  follow  any  irritation  of 
the  mucous  membrane,  which  irritation  results  in  engorge- 
ment of  the  blood  vessels,  swelling  and  succulence  of  the 
mucous  membrane,  with  copious  generation  of  cells  and  an 
abnormal  amount  of  mucus  secretion.  There  are  two 
varieties  of  acute  laryngitis — acute  catarrhal  laryngitis  and 
acute  cedematous  laryngitis — the  first  affecting  the  mucous 
membrane  only,  the  second  affecting  the  sub-mucous  areolar 
tissue.  The  first  mentioned  also  occurs  in  connection  with 
some  of  the  infectious  fevers — measles,  scarletena  and  variola 
— and,  to  some  extent,  it  is  present  in  most  cases  of  bron- 
chitis and  even  in  pneumonia. 

Hippocrates  makes  some  mention  of  a  disease  which  was 
most  likely  laryngitis,  but  we  find  no  other  mention  of  it 
till  the  eighteenth  century,  when  it  appears  to  have  been 
recognized  by  Drs.  Mead  and  Millar,  though  the  latter  ob- 
scured his  picture  of  the  disease  by  confounding  it  with  the 
spasm  of  the  glottis  to  which  his  name  has  been  attached. 
Later  it  was  described  by  Dr.  Hume  in  his  Principia,  and  in 
1809  Dr.  Baillie  gave  a  very  full  account  of  it.  The  first 
dissection  of  the  disease  appears  to  have  been  made  by  Mr. 
Mayd  in  1789,  and  forty  years  later  Guersant  first  gave  a 
clear  account  of  its  pathology. 

Dr.  Ellis,  of  Auckland,  New  Zealand,  says  that  this  "  is  a 
disease  far  commoner  in  adults  than  in  children  ;  still  it 
does  occur  in  children  ;  "  but  on  our  continent,  at  least,  it 
is  a  very  common  disease  amongst  children,  especially  if  the 
variety  affecting  the  rima  glottidis  is  taken  into  considera- 
tion. Acute  catarrhal  laryngitis  occurs  more  frequently  in 
children  under  five  years  of  age  than  in  those  over  that  age, 
and  Duncan  remarks  that  of  sixty-two  well  marked  cases 
met  with,  in  which  the  age  was  noted,  fifty  occurred  in 
children  under,  and  only  twelve  in  those  over  that  age;  most 
of  the  fifty  cases  were   under  two   years   of  age.     It    rarely 


I  [8  \«  i    IT.    CATARRHA1      I  \K\  NGITIS. 

attacks  children  at  the  breast,  though  it  is  not  rare  in  chil- 
dren six  or  seven  months  old.  It  prevails  in  the  fall,  spring 
and  winter  months — especially  in  March  and  April — though 
severe  cases  are  sometimes  met  with  in  summer.  For 
obvious  reasons,  it  is  more  frequently  met  with  in  boys  than 
in  girls. 

Relaxing  habits  and  confinement  indoors  undoubtedly 
predispose  to  this  disease,  and  children  resident  in  towns  are 
more  likely  to  be  attacked  than  those  living  in  the  country. 
Long  continued  and  violent  crying  often  causes  the  disease, 
and  it  may  follow  the  inhalation  of  dust  or  contaminated  air. 
Hut  the  most  common  cause  is  "  taking  cold,"  and  it  often 
follows  sitting  in  a  draft  of  cold  air,  or  permitting  the  child's 
feet  to  remain  wet  and  cold.  Quite  often  a  severe  coryza 
extends  downwards  to  the  larynx,  and,  but  more  rarely,  the 
morbid  process  extends  upward  from  the  bronchial  tubes. 
After  a  child  has  once  suffered  from  acute  catarrhal  laryn- 
gitis other  attacks  are  almost  inevitable. 

The  disease  usually  commences  as  a  common  cold  ;  there 
is  chilliness  followed  by  fever,  with  slight  sore  throat. 
Sneezing  is  often  present,  with  slight  hoarseness,  all  of  which 
symptoms  point  to  a  somewhat  mild  catarrhal  affection 
which  may  suddenly  become  a  serious  malady  with  symp 
toms  of  the  gravest.  Or,  in  the  midst  of  excellent  health,  it 
may  appear  suddenly  in  the  night,  but,  as  a  general  rule,  the 
above-mentioned  prodomata  are  present.  These  symptoms 
persist  for  two  or  three  days,  when  suddenly  the  voice 
becomes  hoarse  or  disappears  altogether,  showing  that  the 
larynx  is  involved,  for  in  that  organ,  and  there  only,  is  the 
voice  formed.  In  the  other  class  of  cases,  the  attack  is 
sudden,  and  the  larynx  is  affected  from  the  first.  The  child 
goes  to  bed  apparently  almost  well,  or  with  but  a  slight 
sneezing  or  coughing,  when,  after  two  or  three  hours  of  sleep, 
he  wakes  up  very  ill  indeed.  There  is  a  hoarse  and  barking 
cough,  ringing  and  croup-like,  and  accompanied  by  expec- 
toration ;  it  is  paroxysmal  and  worse  in  the  evening  and 
during  the  night.     The  cough  is  wholly  laryngeal,  and  some- 


ACUTE    CATARRHAL     LARYNGITIS.  I  19 

times  a  little  tough  mucus  is  raised  with  relief  of  the  local 
symptoms.  If  the  patient  is  able  to  describe  his  feelings, 
complaint  is  made  of  a  dull,  aching  pain  in  the  upper  and 
front  part  of  the  throat,  with  a  marked  feeling  of  constriction, 
which  prevents  the  patient  from  using  the  voice,  even  before 
it  disappears;  there  is  difficulty  of  swallowing,  as  much  from 
the  pressure  of  the  inflamed  larynx  as  from  actual  pharyn- 
gitis ;  the  larynx  is  felt  to  be  enlarged,  hot  and  tender  on 
pressure,  and  the  difficulty  of  breathing  which  is  present 
from  the  commencement  becomes  aggravated.  The  little 
patient  often  puts  the  hands  to  the  throat,  and  at  times  there 
are  spasms  of  the  muscles  of  the  glottis,  from  which  the 
disease  gets  the  name  of  catarrhal  croup.  The  child  is  very 
thirsty,  restless  and  uneasy ;  the  skin  is  dry  and  hot ;  the 
pulse  full,  and  from  100  to  120  in  the  minute.  This  fever, 
with  rapid  pulse,  hot  skin  and  scanty  urine,  assumes  the 
asthenic  type,  from  carbonic  acid  poisoning,  if  the  disease  is 
unchecked.  When  croup-like  cough,  with  markedly  croupous 
breathing,  hoarseness  and  fits  of  choking  are  present,  it  is 
almost  impossible  to  distinguish  the  disease  from  pseudo- 
membranous croup.  But  after  the  symptoms  have  lasted  for 
an  hour  or  two,  the  breathing  becomes  normal  or  nearly  so, 
the  hoarseness  almost  disappears,  moist  rales  appear  in  the 
chest,  general  perspiration  breaks  out,  and  the  child  falls  into 
a  sound  sleep,  usually  accompanied  by  loud  snoring.  The 
most  marked  characteristic  of  the  disease,  then,  is  the  parox- 
ysmal appearance  of  the  stenosis  of  the  larynx  in  the  night, 
alternating  with  the  symptoms  of  catarrh  of  the  larynx 
during  the  day.  This  depends  upon  the  fact  that  during  the 
night  the  copiously-secreted  mucus  settles  in  the  very  narrow 
glottis,  in  fact  almost  closing  the  rima  glottidis,  at  the  same 
time  adhering  to  the  vocal  cords.  This,  of  course,  gives  rise 
to  a  rapidly-increasing  impediment  to  respiration,  till  finally, 
after  coughing  and  crying,  and,  it  may  be,  vomiting,  the 
mucus  is  removed  for  the  time.  Next  morning  the  laryngeal 
stenosis  has  wholly  disappeared,  and  is  replaced  by  the 
catarrhal  laryngitis  with  slight   hoarseness,  and,  though   in 


120  M  nil      c  VTARRHAL     LARYNGITIS. 

some   instances    no    second    attack   comes  on,   it   frequently 
returns  the  next  night. 

If  the  disease  should  prove  uncontrollable,  the  breathing 
becomes  still  more  obstructed,  and  inspiration  requires  an 
unusual  effort,  and  is  hissing  and  whistling.  The  cough 
becomes  still  more  distinctive  in  its  character.  "It  is  brass)' 
in  its  tone,  terminates  in  a  hissing  noise,  and  begins  similarly 
by  a  hissing  inspiration  in  a  muffled  manner,  because  the 
lips  of  the  glottis  being  thickened,  irregular  and  rough,  can- 
not be  sufficiently  closed  to  begin  a  sharp  sound."  (Hyde 
Salter. )  "  As  the  aperture  of  the  glottis  becomes  narrower 
a  terrible  picture  of  distress  presents  itself,  for  strangulation 
seems  to  be  imminent,  ~and  the  patient  tosses  himself 
anxiously  about,  gasping  for  breath  ;  the  face  is  pale  and 
livid,  the  eyes  start  from  their  sockets,  and  the  poor  sufferer 
asks  for  fresh  air,  walks  about,  and  goes  to  the  window  for 
it,  and  finally  delirium  and  coma  close  the  scene  ;  in  fact,  to 
use  the  expression  of  an  able  observer,  he  dies  strangled." 
(Gibb.)  Hoarseness  remains  for  a  number  of  days,  and  in 
the  morning  the  cough  is  so  violent  and  prolonged  that  it  is 
sometimes  difficult  to  convince  the  parents  that  the  child  is 
safe.  I  have  seen  cases  in  which,  after  repeated  attacks  of 
catarrhal  laryngitis,  an  attack  of  true  croup  came  on,  under 
which  the  child  succumbed,  and  this  is  quite  likely  to  occur 
if  such  a  patient  is  attacked  with  measles.  In  other  cases 
again,  chronic  laryngitis  resulted  from  repeated  attacks  of 
the  acute  disease.  If  the  inflammation  is  very  severe, 
oedema  of  the  glottis  may  supervene,  and  the  possibility  of 
this  untoward  event  must  always  be  kept  in  view. 

There  is  a  great  difference  of  opinion  as  to  the  duration  of 
this  disease.  Ellis  thinks  that'it  ought  to  disappear  in  from 
four  to  six  days  ;  Vogel  gives  from  three  to  eight  days  as  the 
average  duration  ;  Von  Niemeyer  says  that  it  ought  not  to 
last  more  than  a  week  ;  Behr  says  that  it  lasts,  at  most,  nine 
days  ;-J.  Lewis  Smith  thinks  that  it  disappears  in  from  one 
to  two  weeks  ;  and  von  Ricmssen  gives  for  mild  cases  five  to 
seven  days,  moderately   severe,  eight  to  fourteen  days,  while 


A.CUTE    CATARRHAL     LARYNGITIS.  121 

the  most  severe,  according  to  this  writer,  run  from  two  to 
three  weeks  or  longer.  Other  excellent  observers  take  a 
more  gloomy  view,  for  DaCosta  writes  as  follows  :  "  The 
disease  in  its  graver  form  runs  a  very  rapid  course.  If,  in  a 
few  days  after  its  commencement,  no  improvement  show 
itself,  life  does  not  last  long.  Sometimes  death  takes  place 
on  the  first  day  of  the  attack.  It  rarely  waits  for  the  sixth." 
Morell  Mackenzie  is  only  a  little  less  gloomy  :  "  The  acute 
stage  seldom  lasts  more  than  three  or  four  days,  and  I  hpve 
seen  a  case  terminate  fatally  in  twenty-four  hours.  Death 
has  been  known  to  occur  in  seven  hours.  It  is  rare  for  the 
symptoms  to  remain  serious  after  the  fifth  day,  unless  a  kind 
of  chronic  cedema  sets  in."  My  own  experience  is  that  the 
duration  of  an  acute  case  is  from  four  days  to  a  week,  and 
decided  danger  is  not  far  off  if  the  disease  is  permitted  to 
run  on  in  a  severe  form  much  longer  than  a  week,  and  this 
danger  may  take  the  form  of  true  croup.  If  the  disease  is 
uncured,  a  chronic  inflammation,  or  rather  congestion,  of  the 
larynx  remains,  which  is  somewhat  difficult  of  cure,  though 
it  must  be  admitted  that  spontaneous  resolution,  or  resolu- 
tion as  a  result  of  therapeutic  interference,  is  far  more  com- 
mon. When  death  takes  place  it  is  usually  the  combined 
result  of  spasm  of  the  glottis  and  cedematous  swelling,  and 
the  fatal  event  is  often  preceded  by  carbonic  acid  poisoning 
with  its  accompanying  delirium. 

The  thermometer  does  not  usually  show  a  marked  rise  in 
temperature  during  the  day,  but  at  night  the  increase  is  very 
marked,  and  the  990  or  99.50  of  the  day  advances  to  1020  or 
even  1030.  The  appearance  of  laryngeal  spasms,  not  being 
due  to  inflammation,  does  not  cause  much  alteration  in  tem- 
perature. 

On  examining  the  larynx  it  is  found  to  be  of  a  bright,  cherry 
red  color,  which  also  extends  to  the  tonsils  and  soft  palate. 
The  mucous  membrane  of  these  regions  is  dry  and  swollen, 
and  the  papillae  are  more  prominent  than  in  health.  The 
epiglottis  is  of  the  same  bright,  red  hue,  and  when  felt  by 
passing  the  forefinger  down  the  throat  it  gives  the  sensation 


\<  I    ii<   \  I'AkkliAl     LARYNGITIS. 

of  a  round  body  of  the  size  and  consistence  <>f  a  ripe  cherry. 
As  a  genera]  thing  the  whole  of  the  pharyngeal  mucous 
membrane  is  of  the  same  bright,  red  color,  and  it  is  greatly 
congested  and  swollen.  The  vocal  cords  are  of  the  same 
color,  though  they  often  have  patches  of  a  darker  shade, 
and,  later  in  the  disease,  a  thick,  adherent  mucus  covers  all 
the  mucous  membrane,  giving  it  a  grayish  tint.  The  dyspnoea 
and  hissing  respiration  are  caused  by  the  swelling  of 
the  vocal  cords,  and  not  by  the  narrowing  of  the  glottis  as 
usually  supposed.  Gerhardt  points  out  that  the  hoarseness 
is  often  the  result  of  a  partial  paresis  of  the  thyro  aretenoid 
muscles,  and  this  often  precedes  the  congestion  of  the 
laryngeal  mucous  membrane,  so  that  the  old  observation 
that  hoarseness  in  a  child  is  of  more  serious  import  than 
hoarseness  in  an  adult  may  be  looked  upon  as  an  established 
fact. 

The  post-mortem  appearances  are  confirmatory  of  those 
observed  during  life,  though,  as  Felix  Niemeyer  remarks, 
the  mucous  membrane  of  the  cadaver  does  not  always  reveal 
a  degree  of  redness  and  vascular  engorgement  such  as  the 
violence  of  the  symptoms  during  life  would  lead  us  to  expect, 
and  such  as  could  then  be  demonstrated  by  laryngoscopic  ob- 
servation. This,  according  to  the  same  acute  observer,  is  due 
to  the  richness  of  the  laryngeal  mucous  membrane  in  elastic 
fibres,  which,  remaining  distended  by  the  blood  contained  in 
the  vessels  during  life,  after  death  contract,  and  expel  the 
contents  of  the  capillaries.  The  disease  is  a  simple  inflam. 
mation  of  the  mucous  membrane  of  the  larynx,  sometimes 
involving  the  sub-mucous  areolar  tissue,  and  accordingly 
there  is  reddening  and  spelling  of  the  laryngeal  mucous 
membrane,  with  a  coating  of  mucus.  It  is  rare  that  the 
larynx  only  is  affected,  for  in  almost  every  case  the  morbid 
process  extends  to  the  pharynx  and  trachea,  producing 
very  similar  post-mortem  appearances.  At  times  the  mucous 
membrane  of  the  larynx  is  abraded  from  the  removal  of  the 
ciliated  epithelial  cells,  but  true  ulceration  is  rarely  present  ; 
if  ulcers  are  present  they  are  most  likely  syphilitic  or  scrofu- 


ACUTE   CATARRHAL    LARYNGITIS,  123 

lous  in  their  nature,  and  were  present  before  the  invasion 
of  the  acute  disease. 

The  diagnosis  of  this  disease  is  easy,  though  sometimes  it 
is  difficult  to  distinguish  it  from  pseudo-membranous  croup, 
for  an  apparently  simple  inflammation  may  really  be  the 
early  stage  of  the  plastic  form  of  the  disease.  In  catarrhal 
laryngitis  the  pharynx  and  tonsils  are  simply  reddened  ;  in 
pseudo-membranous  croup  an  examination  of  the  fauces 
reveals  patches  or  a  continuous  coating  of  pearly-white 
exudation  on  the  soft  palate,  half  arches,  tonsils  and  pharynx. 
In  catarrhal  laryngitis  the  lymphatic  glands  of  the  neck  are 
normal;  in  pseudo-membranous  croup  they  are  often  swollen. 
In  catarrhal  laryngitis  the  fever  remits  during  the  day,  but 
in  pseudo-membranous  croup  the  remission,  if  any,  is  very 
slight.  Indeed,  it  may  be  said  that  the  entire  morbid  process 
of  catarrhal  laryngitis  is  remittent  in  its  character,  for,  though 
the  voice  remains  hoarse  with  a  somewhat  clangorous  cough, 
the  local  affection  and  the  fever  are  so  slight  that  many 
children  amuse  themselves  as  if  nothing  were  the  matter. 
All  this  is  completely  reversed  in  pseudo-membranous  croup, 
and  both  the  local  affection  and  its  accompanying  fever  are 
much  more  pronounced.  Catarrhal  laryngitis  is  at  first 
unaccompanied  by  expectoration ;  and,  as  amendment  sets 
in,  a  slight  expectoration  of  ordinary  mucus  appears ;  while 
the  only  sure  diagnostic  sign  of  pseudo-membranous  croup 
is  the  expectoration  of  fragments  or  tubes  of  false  membrane. 

Catarrhal  laryngitis  may  be  confounded  with  spasm  of  the 
glottis,  but  attention  to  the  following  points  will  at  once 
clear  up  the  difficulty :  Catarrhal  laryngitis  comes  on  gradu- 
ally, while  spasm  of  the  glottis  is  marked  by  a  sudden 
accession.  Catarrhal  laryngitis  has  hoarseness  during  the 
attack,  which  persists  during  the  interval ;  spasm  of  the 
glottis  has  no  hoarseness  at  any  time.  Catarrhal  laryngitis 
has  a  croupy  cough,  worse  at  night,  better  during  the  day  ; 
spasm  of  the  glottis  has  no  cough  whatever.  Catarrhal 
laryngitis  is  unaccompanied  by  constitutional  fever;  spasm 
of  the  glottis  very  rarely  has  fever.     Acute  catarrhal  laryn- 


1-4  Al  i    II'    i   \  l  \kl;ll  \l     LARYNGITIS. 

gitis  may  be  distinguished  from  whooping  cough  by  the  fact 
that  the  latter  disease  has  no  hoarseness,  no  inflammation, 
no  fever  and  no  thickening  of  the  mucous  membrane  of  the 
fauces. 

A  great  variety  of  opinions  exist  as  to  the  prognosis  of 
this  disease,  and  that,  too,  amongst  writers  who  are  clearly 
describing  the  malady.  Ellis  thinks  that  the  prognosis  is 
"very  unfavorable,"  and  Dr.  Morel!  Mackenzie  says  that  "in 
early  life,  that  is  before  the  development  of  the  larynx  has 
taken  place  at  puberty,  the  disease  is  always  attended  with 
great  danger."  According  to  the  same  author,  it  is  more 
fatal  in  children  than  in  adults,  "  more  than  four-fifths  of  the 
mortality  occurring  before  the  tenth  year."  On  the  other 
hand,  Felix  von  Niemeyer  says  that  "  a  fatal  termination, 
uncomplicated  by  any  other  cause  of  death,  is  one  of  the 
greatest  of  rarities,"  an  opinion  which  is  echoed  by  Baehr  ; 
von  Riemssen,  too,  affirms  that  "  a  fatal  result  is  extremely 
rare,"  while  Steiner  thinks  that  "  the  issue  of  acute  laryngeal 
catarrh  in  recovery  is  the  rule  almost  without  exception." 
My  own  experience  is  that  the  prognosis  is  generally  favor- 
able. I  have  never  known  a  fatal  case  under  homoeopathic 
treatment,  and  I  could  scarcely  imagine  such  a  patient  dying 
under  the  care  of  a  well-read  physician  of  our  school.  Favor- 
able signs  are  a  diminution  of  dyspnoea,  freer  expectoration, 
and  less  difficulty  in  swallowing.  The  supervention  of  oedema 
of  the  larynx,  fortunately  rare,  would  greatly  darken  the 
prognosis.  Very  much  depends  upon  the  stage  at  which  the 
physician  is  called  in  ;  should  coma  be  present,  there  is  little 
hope.  Previous  allopathic  treatment  would  diminish  the 
chance  of  recovery,  especially  if  emetics  and  mercurials  have 
been  used.  Still,  it  must  always  be  borne  in  mind  that,  even 
in  healthy  children,  a  simple  catarrhal  laryngitis  may  be 
converted  into  a  true  pseudo-membranous  croup,  and  this 
possibility  should  always  be  present  in  the  physician's  mind. 
This  is  quite  likely  to  take  place  in  children  suffering  from 
measles  or  small-pox. 

In    the  treatment  of  this  disease,  Vogel's  warning  should 


1  ACUTE   CATARRHAL   LARYNGITIS.  125 

ever  be  present  in  the  mind  of  the  physician;  "Pseudo- 
croup  should  never  be  regarded  slightingly,  even  in  its 
mildest  form,  for  very  gradual  transitions  into  the  genuine 
croup  happen,  and,  after  the  fatal  termination  of  which,  we 
may,  when  too  late,  regret  having  carelessly  treated  the 
first  hoarseness."  During  the  entire  course  of  the  disease, 
the  little  patient  should  be  kept  in  bed,  especially  if  the 
weather  is  cold  or  wet,  and  this  should  be  rigidly  enforced 
till  there  is  no  trace  of  hoarseness  left.  The  atmosphere  of 
the  sick  chamber  should  be  uniform,  moist  and  warm,  and  to 
secure  uniformity  a  thermometer  should  invariably  be  used. 
The  warmth  and  moisture  may  be  secured  by  the  genera- 
tion of  steam  in  the  apartment,  and  then  the  affected 
larynx  will  be  kept  from  further  irritation,  for  the  warm 
moisture  prevents  the  drying  of  the  mucous  secretions  of 
the  affected  parts  during  sleep,  and  the  patient  is  spared  the 
terrible  attacks  of  dyspnoea  which  result  from  this  inspissa- 
tion.  The  inflamed  organ  should  be  rested.  On  no  account 
should  the  patient  speak  ;  an  ample  experience  convinces 
me  that  silence  is  often  absolutely  indispensible  to  a  cure. 
I  have  seen  good  results  from  a  warm  compress  to  the 
throat,  but  only  evil  from  the  applications  of  pounded  ice, 
introduced,  I  believe,  by  Dr.  John  Mason  Good.  The  diet 
should  be  bland  and  demulcent,  and  if  dysphagia  is  at  all 
marked,  nutrition  by  the  rectum  should  be  at  once  com- 
menced. 

In  the  prevention  of  acute  catarrhal  laryngitis  the  prac- 
titioner will  soon  discover  the  value  of  Felix  von  Niemey- 
er's  advice.  "  It  is  advisable  rather  cautiously  to  habituate 
children  to  the  causes  of  this  disease,  than  to  enervate 
them  by  a  systematic  over-protection,  which  tends  to 
increase  the  liability  to  its  attacks  upon  every  trifling  occa- 
sion." To  this  end,  the  child  must  not  be  shut  up  in  the 
house  merely  because  it  has  once  had  an  attack  of 
this  disease.  The  little  one  should  be  in  the  open  air  every 
suitable  day,  and,  when  in  the  house,  close  and  over-heated 
rooms,  especially  bed-rooms,  should  be  sedulously  avoided, 


126  \illl     (\  rARRH  \l     L  ^RYNGITIS. 

But,  when  in  the  open  air  the  child  should  not  dawddle 
round  in  the  manner  too  often  seen,  but  should  be  en- 
couraged to  indulge  in  active  exercise.  Flannel  under- 
clothing should  be  worn  in  winter  and  merino  in  summer, 
and  the  underclothing  should  come  high  up  on  the  neck,  but 
the  neck  should  not  be  burdened  with  additional  shawls  and 
mufflers.  F.  von  Niemeyer  tells  us  that  a  silk  ribbon  worn 
about  the  neck  has  the  reputation  of  a  sympathetic  prophy- 
lactic, and,  as  no  harm  can  possibly  result,  it  would  be  well 
to  test  the  somewhat  eccentric  recommendation.  Sponging 
the  entire  body  with  tepid  salt  water  every  morning  has  a 
very  excellent  effect,  though  if  the  throat  and  neck  are 
washed  with  cold  water  the  result  is  still  better.  Von 
Riemssen  advises  the  use  of  the  rubbing  wet  sheet  of  the 
hydropaths,  and  I  can  endorse  the  recommendation  after 
a  long  experience  of  its  good  effects.  "  In  such  cases  it  is 
well  to  have  the  whole  body  rubbed  every  morning  with  a 
large  sheet,  which  has  been  previously  dipped  in  cold  water, 
and  carefully  wrung  out.  As  the  patient  gets  out  of  bed  his 
night  linen  is  removed,  and  the  sheet,  which  is  held  spread 
out,  is  thrown  around  him  from  behind,  so  as  to  cover  the 
head,  but  not  the  face,  and  the  whole  body  down  to  the  feet. 
A  gentle,  rapid  friction  of  the  skin  by  rubbing  with  the 
sheet  will  diminish  the  unpleasant  impression  from  the  cold 
moisture.  After  one  or  two  minutes  of  this  friction  the  wet 
sheet  is  removed,  a  warm,  dry  one  is  thrown  about  the  body 
in  the  same  way,  and  the  body  is  dried.  The  patient  then 
puts  on  his  clothes,  and  immediately  takes  out-door  exercise, 
whatever  the  weather.  If  the  skin  be  very  delicate,  1 
modify  the  treatment  by  at  first  giving  the  water,  into  which 
the  sheet  is  dipped,  a  lukewarm  temperature  (about  86°  F.), 
and  then  lowering  the  temperature  two  degrees  daily,  until 
it  reaches  that  of  spring  water  (50°  to  $6°).  This  treatment 
I  have  adopted  for  several  years,  with  the  best  results  for 
children  as  well  as  adults,  and  the  patients  never  catch  cold, 
if  the  rubbing  be  done  in  a  warm  room  with  the  feet  resting 
on  a  woolen  rug.     After  using  this  treatment  for  eight  days 


ACUTE    CATARRHAL    LARYNGITIS.  1 27 

the  patient  may  be  allowed  to  wear  less  clothing.  During 
the  winter  he  may  continue  to  use  a  fine  woolen  under- 
jacket,  notwithstanding  the  frictions,  but  in  the  spring  this 
garment  must  by  all  means  be  discarded,  and  about  this 
time  the  cold  frictions  are  to  be  resumed,  if  they  are  not 
employed  both  summer  and  winter,  as  is  advisable  in  the 
case  of  children."  Whenever  at  all  practicable,  children 
subject  to  catarrhal  laryngitis  should  spend  at  least  a  portion 
of  each  summer  at  the  seaside,  for  nothing  diminishes  the 
sensitiveness  of  the  skin  and  respiratory  mucous  membrane 
like  the  exhilarating  air  of  the  sea-coast. 

In  almost  every  case  Aconite  is  the  first  remedy  indicated, 
though  Boehr  remarks  that  "  upon  the  whole,  this  remedy 
does  not  seem  often  indicated  in  simple  catarrhal  affections, 
except,  perhaps,  in  the  case  of  children  in  whom  the  febrile 
symptoms  assume  a  different  shape  from  what  they  do  in 
full  grown  persons."  He  adds,  however,  that  "  for  catarrhal 
croup  it  is  undoubtedly  the  best  remedy,  which,  however, 
ceases  to  be  indicated  if  the  physician  be  not  called  till  the 
second  or  third  day  of  the  disease."  It  is  emphatically  the 
remedy  when  the  disease  is  caused  by  exposure  to  keen,  dry, 
cold  air,  and  as  soon  as  the  laryngeal  inflammation  is  lighted 
up,  this  remedy,  if  given  in  repeated  doses,  will  often  cut 
short  the  most  severe  attack.  The  skin  is  hot  and  dry, 
with  full,  quick  and  bounding  pulse  ;  the  voice  is  rough, 
hoarse  and  tremulous  (with  Belladonna  and  Bryonia  the 
voice  is  nasal  o*"  raised) ;  painful  sensitiveness  of  the  larynx, 
with  aggravation  on  coughing  or  speaking  ;  short,  dry  cough, 
with  constant  irritation  ;  during  the  day  the  cough  is  short 
and  panting,  at  night  it  is  rough  and  hollow  ;  accompanying 
this  cough  there  is  expectoration  of  scanty,  whitish  mucus ; 
the  face  and  eyes  are  red  and  flushed  ;  great  thirst  is  present; 
the  sleep  is  broken  and  restless,  and  the  entire  nervous 
system  is  irritable.  I  have  had  the  best  results  from  the  4th 
or  5th  decimal  triturations  of  the  root  of  Aconite,  but  it 
must  prove  curative  in  all  dilutions  and  preparations. 

Sanguinaria   is  indicated  by  dryness  of  the  throat,  with 


1  28  Al   I  Tl.    I    \  I  VRRI1  \l      I    VRYNGITIS. 

soreness,  swelling  and  redness  ;  sensation  of  swelling  in  the 
larynx  and  expectoration  of  thick  mucus;  tickling  in  the 
throat  in  the  evening,  with  slight  cough  and  headache;  dry 
cough,  awakening  him  from  sleep,  which  did  not  cease  until 
he  sat  upright  in  bed,  and  flatus  was  discharged  upwards 
and  downwards ;  tormenting  cough,  with  expectoration  ; 
circumscribed  redness  of  the  cheeks ;  continued  severe 
cough,  without  expectoration  ;  pain  in  the  breast,  and  cir- 
cumscribed redness  of  the  checks.  I  have  used  Sanguinaria 
successfully  in  many  cases  of  laryngitis,  and  I  look  upon  it 
as  being  the  leading  remedy  in  this  disease,  Aconite  not 
excepted.  I  have  generally  used  it  in  the  form  of  an 
acetous  syrup,  as  directed  in  the  chapter  on  pseudo-membra- 
nous croup. 

Spongia  is  a  most  important  remedy  when  croupous 
breathing  appears  in  the  course  of  the  disease.  Laurie  says 
that  it  should,  in  the  generality  of  cases,  be  administered 
six  hours  after  the  last  dose  of  Aconite,  and  Baehr  thinks 
that  it  is  the  principal  remedy  for  this  disease  when  accom- 
panied by  distinct  symptoms  of  oedema  of  the  mucous  lining 
of  the  glottis.  The  cough  is  dry,  barking  and  hollow,  coming 
on  in  paroxysms,  especially  at  night,  with  shrill  and  wheez- 
ing breathing  ;  when  there  is  expectoration  it  is  only  in  the 
morning  (with  Hepar  there  is  expectoration  in  the  morning 
and  during  the  day)  ;  it  is  improved  by  eating  and  drinking, 
worse  when  sitting  erect,  from  motion  and  exertion  (the 
cough  of  Hepar  is  worse  when  lying).  The  larynx  and  upper 
part  of  the  trachea  are  painful  and  sensitive  to  the  touch, 
the  hoarseness  is  very  marked  and  the  patient  speaks  with 
difficulty.  Baehr  remarks  that  Spongia  is  likewise  appropri- 
ate, if  the  croupous  sound  of  the  cough  still  continues,  and 
lumps  of  a  tenacious,  yellow  mucus  are  expectorated.  I 
have  had  the  best  results  from  the  lower  triturations  from 
the  3d  to  the  6th  decimal. 

Hepar  is  very  similar  to  Spongia,  but  there  is  rattling  of 
mucus  in  the  larynx  from  the  commencement ;  the  cough  is 
moist  with  great  hoarseness,  and  slight  suffocative   spasms 


\.CUTE   CATARRHAL    LARYNGITIS.  129 

are  present.  Hepar  is  worse  indoors  and  in  the  morning, 
while  Spongia  is  better  outdoors  and  in  the  morning.  Laurie 
remarks  that  Hepar  may  be  selected  to  follow  Aconite  in 
preference  to  Spongia,  if  the  fever  and  burning  heat  of  the 
skin  continue,  notwithstanding  the  previous  administration 
of  Aconite.  I  have  had  the  best  results  from  this  remedy  in 
the  4th  or  5th  decimal  triturations. 

Tartar  emetic  is  indicated  when  there  is  hoarseness  from 
the  very  beginning  of  the  laryngeal  inflammation,  a  hard  and 
ringing  cough,  or  paroxysmal  fits  of  coughing,  with  suffoca- 
tive arrest  of  breathing  and  profuse  secretion  of  mucus. 
Hartmann  gives  this  remedy  "if  the  inspirations  should 
evince  a  paralytic  condition  of  the  lungs,"  and  in  this  state 
Tartar  emetic  will  help  unless  the  patient  should  be  beyond 
the  reach  of  help.  I  have  succeeded  best  with  the  3d  or 
4th  decimal  triturations  in  repeated  doses. 

Belladonna  is,  according  to  Dr.  Duncan,  of  Chicago,  the 
leading  remedy  in  simple,  uncomplicated  cases  of  this  disease, 
and  we  thank  that  excellent  observer  for  pointing  out  a  fact 
which,  though  recorded  in  our  literature,  had  passed  from 
the  professional  mind.  Very  many  cases  are  simply  conges- 
tion in  the  first  place,  and,  if  Belladonna  is  promptly  given, 
the  results  are  very  striking.  Violent  stinging  pains  in  the 
larynx  are  present,  with  dry  spasmodic  cough,  coming  on  in 
paroxysms,  aggravated  particularly  in  the  evening  and  before 
midnight.  Croupous  breathing  with  hoarseness  is  present, 
and  the  voice  is  low  and  feeble — in  some  severe  cases  this 
proceeds  to  complete  aphonia.  The  pharynx  and  tonsils 
usually  participate  in  the  inflammatory  action,  and  deglutition 
is  difficult  and  painful.  Fever  is  present  with  disposition  to 
perspire  and  to  sleep ;  the  pulse  is  full  and  bounding. 
Laurie  says  that  Belladonna  is  not  to  be  administered  in 
cases  in  which  it  has  been  previously  employed,  as,  for 
instance,  if  the  affection  of  the  windpipe  occurred  immedi- 
ately after  an  attack  of  pure  scarlet  fever.  I  have  commonly 
used  Belladonna  from  the  6th  decimal  to  the  12th  centesimal 
trituration,  though  doubtless  it  would  be  effective  in  almost 
any  dilution. 


130  ACUTE    CATARRHA1     LARYNGITIS. 

Mercurius  solubilis  is  said  by  Baehr  to  act  similarly  to 
Belladonna  in  this  disease,  though  I  have  never  been  able  to 
see  the  resemblance.  There  is  chilliness  and  great  sensitive- 
ness to  cold,  with  frequent  paroxysms  of  dry,  burning  heal, 
alternating  with  copious  perspirations  which  do  not  afford 
relief  ;  the  larynx  is  sore,  the  patient  is  hoarse,  but  there  is  no 
loss  ol  voice;  the  dry,  distressing  cough  occurs  principally 
at  night,  and  the  catarrhal  inflammation  extends  to  the  eyes, 
nose,  pharynx  and  even  to  the  mouth.  I  have  had  the  best 
results  from  this  remedy  in  repeated  doses  of  the  4th  to  5th 
decimal  triturations  given  dry  on  the  tongue. 

Bryonia  is  an  excellent  remedy  to  follow  Aconite,  or,  in 
mild  cases,  from  the  commencement.  The  cough  is  spas- 
modic and  suffocating,  especially  after  midnight,  with  expec- 
toration of  yellowish  mucus,  hoarseness  with  rattling  of 
mucus  in  the  larynx,  and  tenderness  of  the  larynx  on 
pressure.  In  young  children  I  have  usually  given  the  12th 
centesimal  dilution,  but,  on  the  whole,  Bryonia  is  not  so 
useful  in  children  as  in  adults. 

Phosphorus  has  fever  with  hoarseness  and  dry  spasmodic 
cough,  with  stitches  in  the  larynx  and  constriction  of  the 
throat.  The  voice  is  trembling  or  hissing  (in  Bryonia  it  is 
raised  or  nasal),  or  there  may  be  complete  extinction  of  the 
voice.  I  have  had  the  best  results  from  the  12th  centesimal 
dilution,  and  it  is  an  excellent  remedy  to  follow  Aconite. 

Arsenicum  album  is  indicated  by  glowing  fever-heat  with 
constant  thirst;  general  debility  with  a  prostrate  feeling  in 
the  whole  body  ;  burning  pain  in  the  larynx,  increased  by 
deglutition,  which  is  difficult ;  short,  dry,  hoarse  cough  in 
rapid  paroxysms,  with  violent  action  of  the  pectoral  muscles 
during  an  inspiration.  Arsenicum  acts  well  in  all  dilutions; 
I  prefer  the  1 2th  centesimal* 

Lachesis  is  a  valuable  remedy  when  the  larynx  is  raw  and 
dry  and  very  sensitive  to  the  touch.  No  laryngeal  spasm  is 
present,  but  the  patient  is  hoarse,  with  a  feeling  as  though 
something  had  to  be  hawked  up,  and  a  good  deal  of  pain 
and   difficulty  is  experienced   on   swallowing.     Lachesis   is 


ACUTE   CATARRHAL    LARYNGITIS.  131 

often  indicated  after  Hepar,  and  I  have  had  excellent  results 
from  the  12th  centesimal  dilution. 

Minor  remedies  are  Nux  vomica,  useful  during  the  decline 
of  an  attack  after  the  fever  has  abated,  when  there  is  still  an 
evident  sense  of  constriction  during  breathing,  with  a 
constant  tickling,  hawking  cough  with  tenacious  expectora- 
tion ;  Hyosciamus,  useful  when  after  the  cure  of  the  laryngeal 
inflammation,  a  spasmodic  cough,  only  at  night,  remains  to 
harrass  the  patient ;  Argentum  nitricum,  when  the  disease 
tends  to  assume  the  chronic  form,  with  swelling  of  the 
posterior  wall  and  lining  of  the  larynx,  with  hoarseness  and 
loss  of  voice,  continual  and  vain  efforts  to  swallow,  with  pain 
and  soreness  in  deglutition,  much  hawking,  considerable 
muco-purulent  expectoration  or  titillation  in  the  larynx,  with 
dry,  spasmodic  cough  ;  Pulsatilla  when  the  patient  is  chilly 
with  titillating  cough,  excited  by  a  sensation  of  scraping  and 
roughness  in  the  throat,  spasmodic  and  setting  in  more 
especially  in  the  evening  and  when  lying  down,  better  on 
sitting  up,  commencing  again  on  lying  down,  and  some- 
times increasing  to  suffocation ;  lastly,  Hartmann  advises 
Ipecacuanha  or  Sambucus  if,  after  the  abatement  of  the 
fever,  local  symptoms  should  still  remain  with  anxious  and 
hurried  breathing. 

Aphorisms. 

1.  Acute  catarrhal  laryngitis,  also  called  catarrhal  croup,  is 
simply  a  catarrh  of  the  larynx,  which  assumes  the  croupous 
form  when  the  epiglottis  and  rima  glottidis  are  involved. 

2.  The  duration  of  the  disease  is  from  four  days  to  a  week, 
and,  should  it  last  longer  than  a  week,  there  is  a  danger  of 
the  advent  of  pseudomembranous  croup. 

3.  Even  in  healthy  children  a  simple  catarrhal  laryngitis, 
apparently  devoid  of  clanger,  may  be  converted  into  true 
croup — one  of  the  most  serious  of  diseases. 

4.  Even  in  its  mildest  form,  acute  catarrhal  laryngitis 
should  never  be  regarded  slightingly. 


[32  \«  r  1  1     a  DEM  \T<  tUS    LARYNGITIS. 

5.  The  silence  of  the  patient  is  often  indispensible  to  a 
cure.     Rest  the  inflamed  organ. 

\cute  catarrhal  laryngitis  is  best  prevented  by  gradually 
accustoming  children  to  the  causes  of  the  disease,  and  by  the 
judicious  use  of  hydropathic  appliances. 

;.  The  leading  homoeopathic  remedies  are  Aconite,  San- 
guinaria,  Spongia,  Hepar,  Tartar  emetic  and  Belladonna. 

8.  Belladonna,  one  of  the  chief  remedies,  has  been  too 
much  neglected  hitherto  ;  Sanguinaria  will  remove  the  pre- 
disposition to  the  disease. 


CHAPTER  VI. 


Acute    CE  d  e  m  a  t o  u  s    L  a  ryngi  t  i  s  . 


This  disease  is  not  very  common  among  children,  and,  as 
it  occurs  under  varying  conditions,  many  excellent  writers 
consider  it  a  mere  symptom  supervening  on  the  morbid 
states,  but  as  Prosser  James  remarks,  "  it  is  a  condition  so 
important  as  to  deserve  to  rank  separately  as  a  disease." 
Its  rarity  is  accounted  for  by  the  fact  that  in  young  children 
there  is  very  little  submucous  areolar  tissue  in  the  larynx, 
consequently  very  little  field  for  submucous  effusion  during 
inflammations  of  that  organ. 

Acute  cedematous  laryngitis  may  be  defined  to  be  an  in- 
flammation of  the  submucous  areolar  tissue  of  the  larynx, 
resulting  in  infiltration  of  serous,  sero-purulent  or  purulent 
fluid,  accompanied  in  serious  cases  by  stridulous  breathing, 
orthopncea,  and  dysphonia  or  even  aphonia.  The  older  observ- 


ACUTE    (EDEMATOUS    LARYNGITIS.  133 

ers  considered  that  it  was  non-inflammatory  in  its  nature — in 
fact  a  pure  dropsy — but  later  investigations  have  conclusively 
shown  that  inflammatory  (edema  of  the  larynx  is  much  more 
frequent  than  non-inflammatory  infiltration.  The  older 
name — oedema  of  the  glottis— has  been  gradually  abandoned 
for  the  more  appropriate  one  of  oedema  of  the  larynx,  for 
the  glottis  is  not  specially  the  seat  of  this  affection.  Some 
writers  apply  the  term  submucous  laryngitis  to  this  disease, 
but  Trousseau  objects  to  it  on  the  ground  that  it  conveys 
the  idea  of  an  inflammatory  malady,  although  the  name  he 
proposes — anginc  laryngc'c  cede'mateuse — is  open  to  a  similar 
objection.  Bouilland  proposed  the  term  laryngitis  pJdeg- 
inouosa,  indicating  the  identity  of  the  morbid  process  with 
the  phlegmonous  inflammations  of  other  mucous  membranes, 
and  von  Riemssen  has  definitely  adopted  the  term. 

CEdematous  laryngitis  most  frequently  occurs  in  feeble 
children,  and  at  first  it  may  be  mistaken  for  a  '  cold  ';  as  the 
disease  advances,  croup  presents  itself  to  the  mother's  mind. 
Children  who  have  chronic  tonsillitis  are  liable  to  it,  and  in 
such  cases  the  disease  commences  in  a  very  insidious  manner. 
It  may  come  on  when  the  little  patient  is  recovering  from 
measles  or  scarlatina,  and  in  the  latter  disease  it  has  been 
more  frequently  observed  in  patients  who  have  had  the  dis- 
ease in  a  mild  form  than  in  those  who  have  had  a  severe 
attack  ;  indeed,  I  have  come  to  look  for  it,  especially  in 
patients  in  whom  the  disease  has  been  wholly  without  erup- 
tion. It  may  be  developed  during  the  course  of  albuminuria, 
and,  indeed,  in  connection  with  any  disease  on  which 
anasarca  may  supervene.  It  accompanies  tuberculous 
disease  of  the  larynx,  and  in  scrofulous  subjects  suffering 
from  erysipelas  of  the  head  and  face,  the  physician  should 
be  on  his  guard  that  it  does  not  prove  a  suddenly  fatal 
complication.  Sir  Thomas  Watson  says  that  he  has  known 
such  an  inflammatory  oedema  to  arise  from  a  mercurial  sore- 
throat  in  a  broken-down  constitution. 

Acute  cedematous  laryngitis  is  either  primary  ox  secondary, 
though  Dr.  Paul  Guttmann  of  Berlin  opposes  Sestier,  Trous- 


'.vl  VC1    II-    fEDEMATOUS    I  \k\ NGITIS. 

seau,  Mackenzie,  Baehr  and  almost  the  entire  profession  by 
statin-  that  "oedema  of  the  larynx  is  invariably  secondary." 

The  disease  is  said  to  be  primary  when  it  attacks  children 
previously  healthy ;  secondary  when  it  affects  those  already 
suffering  from  disease.  Sestier,  who,  more  than  any  one,  is 
competent  to  speak  with  authority  on  this  disease,  in  one 
hundred  and  ninety  cases  found  thirty-six  primary,  and  a 
hundred  and  fifty-four  secondary.  Again,  the  disease  is 
typical,  when  originating  in  the  larynx,  contiguous  when  it 
spreads  from  the  pharynx  or  other  adjacent  parts,  and 
consecutive  when  it  depends  upon  some  organic  disease  of 
the  larynx.  Again,  the  morbid  state  may  be  either  acute 
or  chronic,  and  at  times  it  assumes  an  epidemic  form,  and  I 
remember  an  epidemic  of  scarlatina,  marked  by  the  preva- 
lence of  oedema  of  the  larynx  in  the  contiguous  form — but 
only  when  the  scarlatina  was  declining.  The  mechanism  of 
the  disease  will  readily  be  understood  when  we  reflect  that 
the  submucous  tissues  are  in  a  state  of  sub-acute  inflamma- 
tion, that  effusion  has  taken  place,  and  that  the  resulting 
swelling  obstructs  respiration,  and,  as  the  swelling  is  usually 
greatest  in  the  epiglottis  and  upper  part  of  the  larynx, 
inspiration  is  more  difficult  than  expiration.  "  Considering 
the  manner  in  which  the  disease  originates,  the  most  correct 
explanation  seems  to  be  that  a  suppurative  process  in  the 
neighborhood  of  the  glottis  causes  oedema  in  the  same  man- 
ner in  which  a  chancre  causes  within  a  few  hours  an  excessive 
redema  of  the  prepuce."  (Baehr).  Again,  the  disease  is 
snpra-glottic  or  sub-glottic,  the  latter  being  an  inflammatory 
oedema  of  the  parts  below  the  vocal  cords,  more  difficult  of 
diagnosis  than  the  supra-glottic  variety,  and,  when  operative 
measures  are  indicated,  calling,  for  tracheotomy  rather  than 
the  scarifications  so  effective  in  the  supra-glottic  variety.  I 
propose  considering  in  this  chapter  the  non-inflammatory 
form  of  fjedema  of  the  larynx,  as  well  as  the  inflammatory, 
although  the  treatment  necessarily  varies  with  the  cause  of 
the  morbid  state. 

None  of  the   medical   writers   of   antiquity    describe  this 


ACUTE    (EDEMATOUS    LARYNGITIS.  1 35 

disease  with  anything  like  clearness,  and  this  is  not  to  he 
wondered  at  when  we  reflect  that  they  merely  described  the 
symptomatic  appearances  observed  during  life,  and  that  they 
were  almost  wholly  ignorant  of  morbid  anatomy.  In  the 
year  1765,  Morgagni,  in  his  famous  work,  De  Sedibus  et 
Causis  Morborum,  first  clearly  described  the  post-mortem 
appearances,  and  later  Boerhaave  and  his  commentator,  Van 
Swieten,  added  to  the  store  of  knowledge.  In  1801,  Bichat 
described  the  malady  as  being  wholly  unique — "  a  particular 
kind  of  serous  swelling  that  does  not  occur  in  any  other 
situation  " — from  which  it  is  evident  that  he  did  not  clearly 
understand  the  mechanism  of  the  disease.  In  1808  Bayle 
presented  to  the  Medical  Society  of  Paris  his  Memoire  sur 
Voedeme  de  la  glotte  on  angine  laryngee  ccdemateuse,  which 
constitutes  the  starting  point  of  a  scientific  knowledge  of  this 
disease.  I  have  not  had  access  to  the  original,  and  authors 
differ  as  to  the  true  nature  of  his  views,  for,  while  von 
Riemssen  states  that  "  Bayle's  cedema  glottidis  is  a  serous 
infiltration  of  the  submucous  connective  tissue,  non-inflam- 
matory in  its  origin,"  his  countryman,  Trousseau,  says,  "  I 
repeat,  that  you  will  almost  constantly  see  cedema  of  the 
larynx  depending  on  inflammation,  a  fact  which  Bayle 
established  and  was  the  first  to  describe."  Finally,  in  1852, 
Sestier  gave  us  a  standard  work,  including  references  to  245 
cases,  not  including  cases  of  scald-throat.  Still  later,  Gibb, 
Mackenzie  and  von  Riemssen  have  systematized  our  knowl- 
edge, and  at  the  present  time  the  disease  is  almost  as  well 
understood  as  any  other  laryngeal  affection. 

The  disease  is  somewhat  rare  in  childhood,  though  there 
is  reason  to  believe  that  many  fatal  cases  are  attributed  to 
other  diseases.  In  215  cases  Sestier  found  only  five  in 
children  under  five  years  of  age,  one  of  them  being  a  new- 
born infant,  and  twelve  cases  between  five  and  fifteen  years. 
Again,  in  245  cases,  Sestier  noted  only  two  primary  cases  in 
children,  and  in  two  other  cases,  between  the  ages  of  four 
and  six  years,  the  disease  arose  by  propagation  from  inflamed 
neighboring  parts. 


o 


"  A.CTJ  II".    ^EDEMATOUS    \..\K\  \<;i  I  IS. 


Acute  cedematous  laryngitis  may  supervene  on  a  slight' 
attack  of  local  inflammation,  as  catarrhal  pharyngitis,  or, 
more  frequently,  erysipelas  of  the  pharynx,  though,  as  a 
general  rule,  it  follows  deeper  seated  affections  of  the  larynx. 
Indeed,  Sestier  asserts  that  "simple  inflammation"  is 
the  cause  of  oedema  of  the  larynx  in  only  six  per  cent,  of  all 
his  cases,  while  in  twenty  per  cent,  of  his  cases  propagation 
took  place  from  the  pharynx;  and  the  pharyngitis  was  in 
many  cases  moderate  and  even  slight. 

CEdematous  laryngitis  almost  constantly  commences  with 
a  chill,  even  when  it  appears  as  an  intercurrent  disease. 
The  chill  alternates  with  flushes  of  heat,  and  soon  the  skin 
is  hot,  the  pulse  full  and  bounding,  and  the  face  red  and 
flushed.  Deglutition  is  difficult,  partly  from  the  pharyngitis 
so  frequently  present,  and  partly  from  the  swollen  epiglottis 
permitting  food  to  enter  the  larynx.  The  external  parts  are 
swollen  in  both  the  primary  and  secondary  varieties  of  the 
disease,  and  the  swelling  is  simply  the  serous  effusion 
following  sub-acute  inflammation.  The  patient  complains  of 
sore  throat,  and  one  of  the  misleading  features  of  the 
malady  is  that,  on  examination,  the  tonsils  and  pharynx 
appear  to  be  the  seat  of  the  disease.  Often  the  patient,  if  old 
enough  to  describe  his  feelings,  complains  of  a  pricking,  burn- 
ing pain  in  some  particular  part  of  the  larynx,  and  this  pain  is 
increased  by  deglutition  and  accompanied  by  a  slight, 
irritative  cough  without  expectoration.  But  soon  the  voice 
gets  rough  and  hoarse,  and  this  rapidly-increasing  hoarseness 
soon  passes  into  almost  complete  aphonia.  At  the  same 
time  complaint  is  made  of  pain  as  if  a  piece  of  wood  or 
other  foreign  body  were  wedged  in  the  larynx,  and  this  gives 
rise  to  repeated  efforts,  by  swallowing  or  by  coughing,  to  clear 
the  throat  of  the  offending  substance.  But  the  harsh  and  pain- 
ful cough  only  results  in  the  difficult  expectoration  of  a  little 
viscid  mucus,  which  brings  no  relief.  The  most  prominent 
symptom, however,  is  an  impediment  to  respiration,  sometimes 
increasing  gradually,at  other  times  with  such  frightful  rapidity 
that  the   fatal   result    takes   place   almost    immediately.     At 


ACUTE    (EDEMATOUS     LARYNGITIS.  137 

first  the  respiration  is  whistling  and  wheezing,  at  an  ad- 
vanced stage  it  is  rasping  and  sawing.  At  the  commencement 
of  the  morbid  state  the  oppression  is  greatest  during  inspira- 
tion, which  requires  considerable  effort  and  is  accompanied 
by  a  kind  of  snoring  noise,  especially  during  sleep.  Expira- 
tion, of  course,  is  performed  more  readily  than  inspiration, 
for  the  swollen  membrane  closes  like  a  valve  against  the 
entrance  of  air,  but  readily  permits  it  to  pass  out.  As  the 
disease  advances,  however,  expiration,  hitherto  easy,  noise- 
less and  hardly  perceptible,  becomes  difficult  and  the  dysp- 
noea rapidly  increases.  There  is,  however,  even  in  cases  in 
which  permanent  obstruction  is  present,  the  same  tendency 
to  remissions  and  exacerbations  that  characterizes  almost  all 
affections  of  the  larynx,  though  the  paroxysms  may  last  as 
lono;  as  ten  to  fifteen  minutes,  during  the  whole  of  which  time 
suffocation  appears  to  be  imminent.  During  the  paroxysm 
the  patient  stands  up  from  the  bed  and  instinctively  makes 
for  the  window  with  mouth  wide  open,  agonizing  for  breath. 
The  face  is  livid  and  cool,  the  nostrils  are  distended,  the 
eyes  seem  to  start  from  the  head,  the  whole  body  is  tremb- 
ling and  convulsed,  and  the  skin  is  bathed  in  perspiration,  the 
cough  becomes  less  frequent,  and  as  the  disease  advances  it 
disappears  altogether,  as  the  patient  cannot  inflate  the  lungs. 
As  the  carbonic  acid  poisoning  advances  the  face  becomes  of  a 
dusky,  bluish  hue,  delirium  appears,  during  which  the  sufferer 
tears  at  his  neck  in  a  kind  of  frenzy,  and  unless  prompt 
relief  is  given  he  dies  strangled. 

Should  a  favorable  change  take  place,  all  the  symptoms 
abate  ;  the  difficulty  of  breathing  diminishes,  though  it  still 
remains  somewhat  embarrassed,  especially  during  inspiration  ; 
the  cough  becomes  easier  and  more  sonorous  ;  the  voice  once 
more  becomes  audible.  It  is  some  time  before  the  little 
patient  recovers  from  the  effects  of  such  a  storm,  and  he 
must  be  carefully  guarded  against  relapses. 

From  first  to  last  the  disease,  in  its  primary  form,,  may  last 
from  three  to  five  days  ;  as  an  intercurrent  disease,  it  may 
prove  fatal  in  a  few  hours.     Baehr  says  that  the  affection  may 


i.}X  \»i   ri     >i  DEM  vnu  s    i..\k\  \<;i  i  is. 

last  from  twelve  hours  to  upwards  of  a  week,  and  von 
Riemssen  holds  that  highly-acute  diffuse  infiltration  runs  its 
course  under  the  most  stormy  manifestations,  and  may  cause 
death  within  a  few  hours  or  even  minutes,  through  closure 
of  the  laryngeal  entrance,  if  the  right  help  is  not  afforded 
at  the  right  time.  Prof.  George  P.  Wood  thinks  it  probable 
that  life  is  sometimes  suddenly  terminated  by  the  superven- 
tion of  spasm  of  the  glottis,  and  the  writer  has  seen  cases  in 
which  this  has  actually  occurred. 

Scald-throat,  as  it  is  popularly  called,  is  a  very  common 
and  very  fatal  form  of  (edematous  laryngitis  among  the  chil- 
dren of  the  laboring  classes  in  England,  and  indeed  in  every 
country  in  which  tea  is  an  ordinary  beverage.  The  accident 
usually  happens  to  young  children  in  the  mistaken  attempt 
to  drink  boiling  water  from  the  spout  of  the  tea-kettle.  The 
boiling  water  rarely  reaches  the  oesophagus,  for  it  is  expelled 
by  the  spasmodic  action  of  the  muscles  of  the  pharynx,  but 
it  has  had  time  to  come  in  contact  with  the  inside  of  the 
mouth,  the  epiglottis  and  aryteno-epiglottidean  ligaments. 
Probably  the  screaming,  caused  by  the  acute  pain,  causes  a 
sudden  inspiratory  effort  which  draws  the  boiling  water,  and 
still  more  readily  the  heated  steam,  towards  the  larynx. 
Even  when  the  larynx  itself  is  not  scalded,  it  soon  becomes 
involved  by  extension  of  inflammation  from  the  pharynx. 
Sometimes  a  deceitful  calm  of  an  hour  or  two  follows  the 
scald,  when  suddenly  the  laryngeal  symptoms  are  developed, 
and  the  state  is  at  once  alarming  in  the  extreme.  More 
commonly,  hoarseness  and  dysphagia  appear  at  once,  accom- 
panied by  inflammatory  fever,  and  this  is  followed  in  a  few- 
hours  by  cedema  of  the  larynx,  with  difficult  inspiration, 
hoarse,  croupous  breathing,  and  even  spasm  of  the  glottis. 
The  morbid  state  marches  on  with  frightful  rapidity,  the  face 
becomes  bluish,  the  hands  and  feet  cold,  the  breathing  more 
and  more  oppressed,  the  voice  becomes  extinct,  and  death 
takes  place  by  suffocation. 

The  post-mortem  appearances  in  cases  of  scald-throat  are 
those  of  intense  inflammation  of  mucous  membrane  of  all 


ACUTE    (EDEMATOUS    LARYNGITIS.  1 39 

the  affected  parts,  and  especially  the  mucous  membrane  of 
the  epiglottis  and  of  the  aryteno-epiglottidean  ligaments  is 
thickened  from  effusion  into  the  sub-mucous  areolar  tissue. 
Sometimes  the  opening  of  the  larynx  is  quite  closed,  but  the 
(t'dema  never  extends  below  the  vocal  cords.  When  death 
is  very  speedy,  and  speedy  deaths  are  very  common  here,  the 
mucous  membrane  below  the  rima  glottidis  may  be  quite 
normal,  but  when  the  patient  has  survived  for  some  days  the 
trachea  and  bronchial  tubes  are  inflamed,  and  the  lungs 
congested,  or  even  hepatized. 

Not  even  Wunderlich,  with  his  tireless  industry,  has  given 
us  any  observations  as  to  the  temperature  of  the  body  in 
this  dreaded  disease,  and  personally,  when  I  had  a  case,  I 
thought  more  about  the  lancet  than  the  thermometer. 

The  inflammation  present  in  cedematous  laryngitis  is  of  a 
low  grade,  and  the  effusion  is  produced  in  the  sub-mucous 
areolar  tissue  as  the  result  of  inflammatory  action  in  that 
membrane,  or  as  the  result  of  inflammation  in  adjoining 
parts,  as  Baehr  has  so  well  pointed  out.  As  a  general  rule, 
the  affected  parts  have  the  usual  red  hue  of  inflammation, 
but  about  the  entrance  to  the  larynx  they  are  often  trans- 
parent, fluctuating  and  of  a  pale-yellow  color,  especially  the 
parts  well  supplied  with  areolar  tissue,  as  the  duplicature  of 
the  aryteno-epiglottidean  ligament.  These  bulge  out  in  two 
loose  and  pendulous  rolls  extending  backwards  to  the 
pharynx,  while  the  bloated  epiglottis  projects  high  above 
the  root  of  the  tongue.  Sometimes  but  one  of  these 
ligaments  is  affected,  and  a  single  transparent  swelling  closes, 
more  or  less,  the  entrance  of  the  glottis.  Sometimes,  but 
rarely,  the  sub-mucous  tissue  of  the  vocal  cords  is  affected, 
and  the  sub-glottic  form  of  the  disease,  so  well  described  by 
Sir  George  Duncan  Gibb,  is  almost  as  rare,  simply  because, 
as  he  points  out,  "  the  sub-mucous  tissue  at  the  upper  part 
of  the  larynx  is  loose,  and  quickly  admits  of  infiltration  and 
swelling,  or  oedema,  during  inflammation  ;  but  below  as  well 
as  in  the  trachea,  it  is  less  in  quantity,  and  of  a  more  dense 
quality,  therefore,  inflammation  is  not   succeeded  so  rapidly 


140  ACUTE    a  DEM  \  mi  -     LARYNGITIS. 

by  sub-mucous  effusion  as  it  is  by  exudation  of  lymph  upon 
its  surface."  At  times  the  oedema  extends  down  the  trachea, 
but  Sestier  detected  it  only  seven  times  in  132  cases  of 
oedema  of  the  upper  air  passages.  Very  commonly,  the 
neighboring  muscles  are  saturated  with  the  serous  or  sero- 
purulent  fluid.  Generally  the  effused  fluid  is  sero-purulent, 
for  pure  scrum  is  found  only  in  the  foudroyante  cases  ; 
according  to  Sestier  blood  is  often  mingled  with  serum  in  that 
very  class.  In  the  more  chronic  cases  the  fluid  is  quite 
purulent. 

The  diagnosis  of  (edematous  laryngitis  is  surrounded  by 
difficulties,  yet  much  depends  upon  the  disease  being  recog- 
nized at  an  early  stage.  Some  physicians  include  all 
laryngeal  diseases  of  children  under  the  generic  name  of 
"croup,"  and  such  a  wholesale  ignoring  of  pathology  must 
result  in  a  largely-increased  mortality  in  this  class  of  diseases. 
M.  Thuillier's  test,  insisted  on  by  all  practitioners  who  have 
studied  the  disease,  is  almost  decisive  as  to  the  existence  of 
the  supra-glottic  variety,  though,  for  anatomical  reasons,  it 
affords  us  little  or  no  help  when  the  disease  is  sub-glottic. 
By  simply  depressing  the  tongue,  the  epiglottis  rises  as  a 
pale  or  reddish,  pear-shaped  swelling  behind  the  root  of  the 
tongue.  Then  when  the  index-finger  is  rapidly  but  gently 
passed  into  the  larynx,  the  oedematous  swelling  can  be 
distinctly  felt.  With  one  hand  the  physician  should  press  up 
the  os  hyoides  so  as  to  bring  the  glottis  more  within  reach, 
while  the  forefinger  of  the  other  hand  is  engaged  in  explora- 
tion, but,  as  already  remarked,  we  can  only  detect  the 
oedematous  swelling  of  the  epiglottis  and  aryteno-epiglotti- 
dean  ligaments.  Dr.  George  B.  Wood  thinks  that  this  mode 
of  examination  must  be  difficult,  and  that  it  might  possibly 
aggravate  the  inflammation,  but  in  practice  one  almost 
always  succeeds,  though  with  varying  facility.  Trousseau 
observes  that  exploration  by  the  finger  must  be  practiced  in 
a  very  careful  manner,  and  he  adds  that  while  he  was  exam- 
ining the  throat  of  a  woman  in  the  most  guarded  possible 
way,  he  induced  a  suffocative    seizure,    which    very    nearly 


ACUTE    (EDEMATOUS    LARYNGITIS.  141 

proved  fatal.  In  adults  the  laryngeal  mirror  would  aid 
much  in  the  diagnosis,  but  it  is  difficult  to  use  it  in  children. 

Acute  cedematous  laryngitis  is  very  likely  to  be  confounded 
with  croup,  and  in  very  many  points  there  is  a  very  strong 
resemblance.  It  resembles  croup  in  the  difficulty  of  breath- 
ing, the  suffocative  fits  and  the  cough,  the  hoarse  voice,  and 
the  noisy,  stridulous  inspiration,  and  even  in  the  intermis- 
sions between  the  paroxysms,  which,  indeed,  are  common  to 
all  laryngeal  diseases.  But  oedema  of  the  larynx  chiefly 
occurs  as  an  inter-current  disease  in  children  suffering  from 
some  malady  of  the  adjacent  parts,  while  croup  almost 
always  attacks  children  in  good  health.  Again,  the  cough 
of  cedematous  laryngitis  has  not  the  croupous,  brassy  sound 
of  the  cough  of  croup.  In  cedematous  laryngitis  the  diffi- 
culty of  breathing  is  greatest  in  inspiration,  while  expiration 
is  comparatively  free,  but  in  croup  of  any  kind  inspiration  is 
as  difficult  as  expiration.  Lastly,  cedematous  laryngitis  has 
no  exudation  in  the  pharynx  and  no  expectoration  of  mem- 
branous shreds  as  in  true  croup. 

The  sub-glottic  variety  is  distinguished  from  the  supra- 
glottic  by  the  absence  of  the  shrill  whistling  inspiration  so 
marked  in  oedema  of  the  upper  part  of  the  larynx,  and  on 
examining  with  the  finger  the  epiglottis  and  aryteno-epig- 
lottidean  folds  are  normal  or  nearly  so.  Sir  G.  D.  Gibb 
points  out  that  the  effusion  in  the  sub-glottic  variety  is  "inva- 
riably fibrinous,"  never  serous  as  in  the  supra-glottic  form, 
and  he  says  that  it  may  be  taken  as  a  curious  and  undisputed 
fact  that  the  sub-glottis,  from  its  anatomical  peculiarities, 
secretes  fibrin  which  may  be  poured  out  on  the  surface  of  the 
membrane  or  beneath  it,  according  to  the  special  exciting 
circumstances  inducing  it.  It  is  undoubtedly  true  that  the 
parts  below  the  glottis  are  less  abundantly  supplied  with 
sub-mucous  areolar  tissue  than  the  supra-glottic  region,  and 
also  that,  as  a  general  rule,  the  tendency  of  that  part  of  the 
larynx,  when  inflamed,  is  to  throw  out  fibrin,  but  Bur"ow, 
Rauchfuss  and  Lefferts  of  New  York  have  all  reported 
unquestionable    cases    of     sub-glottic    oedema    in    children. 


i  I  •  \(  I    II'.    i  I  hi  \i  \|(  IUS     LARYNGITIS. 

Mackenzie  says  that  all  the  examples  of  sub-glottic  oedema 

he  has  met  have  been  of  a  chronic  character,  but,  curiously 
enough,  all  the  present  writer's  cases  were  acute,  similating 
membranous  croup  very  closely  indeed. 

(Edematous  laryngitis  is  always  a  most  serious  disease, 
even  when  recognized  at  its  inception.  Indeed,  the  prog- 
nosis is  favorable  only  when  the  grade  of  the  disease  is  not 
at  all  marked  and  when  the  inducing  cause  has  ceased  to 
progress,  or  when  the  oedema  affects  only  one  aryteno- 
epiglottidean  fold  or  but  one  side  of  the  epiglottis.  Baehr 
says  that  "the  most  common  termination  is  death  by 
suffocation,  and  the  prognosis  is  consequently  that  of  inevi- 
table death  ;"  von  Riemssen  teaches  that  "  the  higher  grades 
of  laryngeal  stenosis,  due  to  sub-mucous  infiltration,  usually 
terminate  in  death  if  timely  interference  does  not  prevent," 
while  Prosser  James  states  that  "  if  not  relieved  it  will  be 
fatal  in  a  few  hours,  and  cases  are  recorded  in  which  no 
warning  preceded  death,  which,  therefo-e,  may  be  termed 
sudden." 

Bayle,  writing  when  the  mechanism  of  the  morbid  process 
was  but  little  known,  reports  seventeen  cases  with  but  a 
single  recovery.  Sestier  compiled  statistics  of  almost  all  the 
authentic  cases  on  record,  and  the  mortality  was  158  in  213 
cases,  though  the  trachea  was  opened  in  thirty  of  the  fatal 
cases.  In  the  55  recoveries,  tracheotomy  was  performed 
twenty  times.  The  primary  form  of  the  disease  is  less 
dangerous  than  the  secondary,  and  typical  oedema — the  form 
originating  in  the  larynx  itself — is  almost  invariably  fatal. 
"When  oedema  of  the  larynx  is  a  primary  affection,  or  is 
connected  with  acute  inflammation  of  the  pharynx  or  larynx, 
its  progress  is  more  rapid,  and  the  chances  of  a  favorable 
termination  are  also  greater,  which  arises  from  the  affection 
being  transient  in  its  nature  like  the  pathological  state  011 
which  it  depends"  (Trousseau).  If  the  inflammatory  action 
should  originate  in  the  pharynx,  the  prognosis  is  compara- 
tively favorable,  but  if  it  commences  in  the  areolar  tissue  of 
the  neck  it  is  almost  invariably  fatal.     Still,  one  of  the  worst 


ACUTE    (EDEMATOUS    LARYNGITIS.  143 

cases  the  present  writer  ever  saw,  commenced  in  the  areolar 
tissue  of  the  neck,  and  was  cured  by  Sanguinaria,  as  detailed 
in  the  remarks  on  therapeutics.  If  the  disease  has  its 
starting  point  in  syphilis,  as  is  not  seldom  the  case  with 
children,  the  morbid  state  is  generally  curable,  but  if  it 
should  occur  during  the  course  of  typhoid  fever,  the  case 
will  likely  prove  fatal.  The  supra-glottic  form  is  more 
dangerous  than  the  sub-glottic,  simply  because  the  parts 
above  the  glottis  are  richest  in  areolar  tissue.  It  is,  of  course, 
less  dangerous  in  a  child  of  good  constitution  than  in  one  of 
scrofulous  diathesis  or  in  feeble  health.  Habitual  disease  of 
the  larynx  would  materially  darken  the  prognosis,  and  when 
the  disease  supervenes  upon  chronic  laryngitis,  it  is  almost 
incurable.  In  the  advanced  state,  when  asphyxia  has  already 
commenced,  there  can  be  but  little  hope,  for,  even  if  the 
dyspnoea  is  relieved,  the  nervous  system  may  be  unable  to 
rally  from  the  prostrating  influence  of  the  poisoned  blood. 

Speaking  of  laryngitis,  Dr.  Richard  Hughes  observes, 
"should  oedema  glottidis  supervene,  repeated  doses  of  Apis 
would  give  the  best  chance  of  averting  tracheotomy,"  and 
in  his  latest  work  he  further  says,  "  It  (erysipelatous  sore 
throat)  is  often  the  beginning  of  oedema  glottidis,  in  which 
Apis  is  the  great  remedy.  It  has  proved  curative  in  more 
than  one  instance  of  this  affection,  where  the  cause  was 
drinking  water  from  a  kettle.  Such  cases  are  commonly 
fatal."  Again,  in  his  excellent  Manual  of  Therapeutics :  "I 
think  that  the  best  advice  I  can  give  you  as  to  the  treatment 
of  this  dangerous  condition  (oedema  glottidis),  under  what- 
ever circumstances  it  may  occur,  is  to  trust  to  Apis.  Since 
this  remedy  has  cured  it  even  in  its  most  fatal  form — viz.,  that 
which  occurs  in  children  after  drinking  from  the  spout  of  a 
tea-kettle — it  will  probably  be  competent  to  deal  with  all 
other  forms  of  the  malady."  Dr.  Holcombe  observes  that 
Apis  is  especially  indicated  when  the  attack  has  suddenly 
sprung  up  in  the  course  of  an  acute  disease,  in  otherwise 
healthy  persons,  and  that  it  is  still  more  so  when  it  occurs 
n    erysipelas,  burns,  or   the    eruptive   fevers    to   which  the 


1. 1  I  \cin'K    (1.1  »EMATI  >US     LARYNGITIS. 

bee-virus  has  more  or  less  affinity.  Baehr  regards  it  .is  one 
of  the  three  remedies  which  act  similarly  to  the  general 
disease — the  others  being  Lachesis  and  Rims  toxicodendron. 
I  look  upon  Apis  as  being  undoubtedly  the  first  remedy  to 
be  thought  of,  though,  of  course,  it  does  not  cover  all  cases. 
Still,  I  have  succeeded  with  it  when  success  seemed  to  be 
unattainable,  llolcombe  recommends  the  3d  dilution  to  be 
used;  I  always  use  the  5th  decimal  trituration  of  the  sting 
of  the  bee  and  the  attached  sac  of  the  virus,  for,  as  Constan- 
tine  Hering  remarks,  "there  is  but  one  right  kind,"  and 
that  is  it. 

An  English  physician,  Dr.  Ainley,  of  Halifax,  communi- 
cates the  following  excellent  case  to  the  Hovuvopathic  World, 
vol.  XIV  : 

"  In  November,  1878,  I  was  summoned  at  1 1  P.  M.  to  see 
a  little  boy,  aged  four  years,  who  had  been  taken  ill.  The 
history  of  the  case  was  that  he  had  been  all  right  up  to  tea- 
time,  and,  indeed,  on  being  put  to  bed  at  8.30  appeared  the 
same,  but  on  being  looked  at  by  the  parents  before  they 
retired  to  rest,  as  was  their  custom,  they  found  him  breath- 
ing very  heavily,  and  were  alarmed  and  sent  for  me.  When 
I  arrived,  in  a  moment  I  diagnosed  "  croup  " — that  is  to  say 
without  asking  any  questions — and  seeing  no  time  was  to  be 
lost,  as  the  boy's  face  was  already  blue  and  swollen  from 
impeded  respiration  and  deficient  aeration,  I  began  to 
prescribe  my  usual  remedies,  and  which  1  am  thankful  to  say 
usually  succeed,  viz.:  Aconite  and  Sjbgngia,  administered 
every  ten  minutes  in  alternation.  But  asl  anxiously  watched 
the  case,  feeling  sure  a  short  time  would  decide  for  or 
against,  I  entered  into  conversation  with  the  parents,  and 
began  to  make  fuller  inquiries  into  the  previous  history  of 
the  child,  and  the  following  little  incident  was  told  me,  which 
of  course  turned  the  whole  case  :  On  the  same  day,  at  tea- 
time,  when  the  mother  had  just  filled  up  the  teapot  with  hot 
water,  and  left  it  on  the  edge  of  the  table,  the  little  fellow 
drank  out  of  the  teapot-spout,  and  although  it  was  very  hot, 
he  seemed  to  make  no  complaint  of  any  pain   in   his  throat, 


ACUTE    CEDEMATOUS     LARYNGITIS.  145 

and  played  for  some  time,  and  even  went  to  bed  without 
complaining.  Here  we  had  an  entirely  new  condition  of 
things,  which  could  have  had  no  true  interpretation  apart  from 
the  incident  just  related  ;  symptomatically  it  was  a  case  of 
"  Cynanche  Trachealis  ;  "  pathologically  it  was  "  Cynanche 
Trachealis ;"  and  I  suppose  if  one  had  searched  through  all 
the  homoeopathic  literature  extant  only  one  medicine  could 
have  been  found  to  have  met  the  case,  and  that  was  Apis. 
Apis  was  promptly  given,  and  in  from  four  to  six  hours  all 
danger  might  be  said  to  be  over." 

Dr.  Bruckner,  of  Basle.,  publishes  an  interesting  case  in 
the  A.  N.  Z.,  1873,  of  which  the  following  epitome  is  given 
by  Raue  in  the  Annual  Record  for  1874  :  "  A  young  man, 
who  had  scarlet  fever  as  a  child,  suffered  from  that  time  from 
an  ©edematous  swelling  of  some  part  of  his  body,  regularly 
returning  every  eight  days.  For  the  last  three  years  it  threw 
itself  sometimes  on  the  glottis,  causing  fits  of  suffocation, 
but  always  terminating  in  twelve  hours.  Before  the  paroxysm 
attacks  of  bilious  vomiting.  Relieved,  but  not  cured,  by 
Apis  200." 

In  1869  I  wrote  :  ';  I  have  never  had  an  opportunity  of 
testing  the  virtues  of  Sanguinaria  in  this  disease,  but  would 
expect  considerable  from  it ;"  and  in  the  month  of  April, 
1874,  I  had  the  long-looked  for  opportunity.  On  Friday, 
April  17,  1874,  I  was  called  to  Mrs.  C,  aged  59,  who  had 
been  complaining  for  some  few  days.  I  found  an  inflamma- 
tion of  the  cervical  glands  of  the  right  side,  involving  the 
parotid  gland  to  a  considerable  extent,  and  accompanied,  by 
extensive  inflammation  of  the  subjacent  cellular  tissue.  The 
parts  were  hot,  tender,  swollen  and  red — in  fact,  the  well- 
known  calor,  dolor,  tumor,  rubor — and  there  was  reddening 
of  the  fauces,  with  slight  pain  on  deglutition.  I  prescribed 
Belladonna,  6th  decimal  trituration,  and  advised  rest,  quiet 
and  silence.  On  the  following  day  the  situation  was  but 
little  changed,  and  Mercurius  iodatus  ruber,  3d  decimal 
trituration,  was  prescribed. 

At  6  o'clock  of  Sunday  morning,  April  19th,  I  received  an 


1. 1"  \C\    ||      .|  hi  \]  \ToIS     LARYNGITIS. 

urgent  call  to  the  patient,  who,  I  was  told,  had  hardly  been 
able  to  breathe  all  night.  I  found  her  sitting  up  in  bed, 
with  a  characteristic  rasping  and  sawing  sound  issuing  from 
the  larynx,  a  sound  somewhat  difficult  of  description,  but 
which  once  recognized  can  never  be  forgotten.  The  tonsils 
and  pharynx  were  swollen,  but  auscultation  showed  that  the 
sawing  and  rasping  sound  issued  from  the  larynx.  The 
cough  was  dry  and  harsh,  relieved  by  sitting  up  in  bed, 
aggravated  by  eating  and  lying  down,  and  it  was  accom- 
panied by  difficult  expectoration  of  tough  and  glairy  mucus. 
The  voice  was  low  and  suppressed,  and  it  was  with  difficulty 
that    I   could   make   out    the    hurried,  whispered   sentences. 

The  pulse  was  feeble  and  fluttering,  and  the  lips  were 
pale  ;  but  on  both  cheeks  there  was  a  circumscribed  redness. 
The  pathognomic  symptom  which  made  the  pathological 
state  quite  clear  to  me  was  the  fact  that  expiration  was 
performed  more  readily  than  inspiration.  M.  Thuillier's  test 
was  decisive  as  to  the  diagnosis,  for"  when  the  forefinger  was 
passed  into  the  larynx,  there  is  a  perception  of  a  cushion 
formed  by  the  tumefaction  of  the  sides  of  the  glottis — a  soft, 
pulpy  body,  quite  distinct  from  the  ordinary  hard  feel  of  the 
parts." 

The  diagnosis  was  acute  oedematous  laryngitis  of  the 
supra-glottic  variety — all  the  more  dangerous  because  it 
was  an  intercurrent  disease — and  the  peculiar  respiration 
arose  from  the  fact  that  the  (edematous  membrane  which 
filled  the  glottis  closed  like  a  valve  against  the  entrance  of 
air,  but  readily  permitted  it  to  pass  out.  I  prescribed 
Sanguinaria  1st  decimal  trituration,  a  dose   every  half   hour. 

At  i  I'.  M.  I  found  that  improvement  had  commenced 
almost  as  soon  as  the  medicine  was  given.  The  sawing  and 
rasping  sound  was  now  much  diminished,  the  respiration 
was  comparatively  easy,  inspiration  and  expiration  were 
performed  with  equal  facility,  the  cough  was  less  frequent 
and  less  severe,  the  voice  was  quite  audible,  and  the  patient 
had  slept  much  of  the  time  since  morning.  The  tonsils  and 
pharynx  were  still  red  and  swollen,  but  the  glottis  was  clear 


ACUTE    CEDEMATOUS     LARYNGITIS.  147 

of  the  tense  and  rounded  swellings  present  in  the  morning. 
The  Sanguinaria  was  continued  in  the  same  dose. 

At  7  P.  M.  I  again  saw  the  patient  and  found  that  the  very 
serious  pathological  state  had  almost  wholly  disappeared. 
The  Sanguinaria  was  continued  all  night,  and  in  the  morning, 
as  the  acute  oedematus  laryngitis  was  no  longer  present, 
treatment  was  directed  against  the  inflammation  of  the 
cervical  glands  and  cellular  tissue."' 

"  Should  Apis  fail  you,  however,  you  may  (before  thinking 
of  surgical  measures)  consider  the  claims  of  Sanguinaria." 
(Hughes.) 

In  1869  I  suggested  Aconite  as  a  leading  remedy,  and, 
although  no  other  writer  of  our  school,  save  Charles  Julius 
Hempel,  has  endorsed  the  recommendation,  I  repeat  the 
suggestion  with  all  the  more  confidence  that  I  have  found 
its  action  prompt  and  decided  in  several  well-marked  cases. 
But  it  must  be  given  in  repeated  doses  of  the  mother  tinct- 
ure, or  1st  decimal  dilution. 

Dr.  Jacob  Reed,  Junior,  of  Philadelphia,  reports  the 
following  case:  "March  16,  1867,  evening.  Called  to  see 
Miss  B.,  at  20,  who  had  for  some  days  '  had  a  bad  sore 
throat,'  and  was  reported  as  choking  to  death.  When  seen, 
the  patient  was  evidently  suffering  from  an  acute  oedematous 
inflammation  of  the  larynx,  there  being  high  fever,  pain  in 
the  region  of  the  larynx,  difficulty  of  swallowing  and  breath- 
ing, voice  almost  inaudible,  every  effort  at  speaking  causing 
great  pain,  inspirations  prolonged  and  stridulous,  being 
effected  only  by  violent  effort ;  there  was  but  little  cough  ; 
frequent  spasmodic  exacerbations  of  these  symptoms  ren- 
dered suffocation  imminent.  Ordered  inhalations  of  steam 
medicated  with  Opium,  cold  pack  to  the  region  of  the 
larynx,  Aconite  and  Kali  bichromicum  ;  of  the  Aconite  three 
drops  of  the  tincture  of  the  root  were  given  in  a  half  glass  of 
water,  of  which  she  took  a  teaspoonful  every  twenty  minutes. 
This  appeared  to  afford  relief,  which,  however,  proved  but 
temporary,  as  upon  paying  my  morning  visit,  I  found  the 
patient    much    worse  in    every  respect,  the    leaden   hue    of 


i.(S  \.  in      .|  ihmah  us     LARYNGITIS. 

the    skin,   with    the   intense    anxiety   of    tin-    countenance, 

showing  that  she  had  to  fear  the  result  of  deficient 
aeration  of  the  blood.  This  condition  of  affairs  rendering 
tracheotomy  necessary,  I  returned  to  the  office  for  the 
necessary  instruments  and  assistance,  but  in  the  meantime 
ordered  two  drops  of  the  tincture  of  the  Aconite  root  to  be 
given  every  ten  minutes.  Upon  returning  after  the  lapse  of 
an  hour,  the  patient  was  so  far  relieved  as  to  render  surgical 
interference  unnecessary,  and  from  this  the  convalescence 
was  stcad\-,  although  slow  and  imperfect.  There  remains, 
after  many  months,  a  cough,  with  hoarseness,  owing  to 
constitutional  tuberculosis." 

According  to  Baehr,  "  we  are  acquainted  with  only  one 
remedy  which  has  cedema  of  the  glottis  among  its  physio- 
logical effects;  that  remedy  is  Iodium."  Holcombe,  too, 
advises  it  and  I  look  upon  it  as  being  one  of  our  chief 
remedies.  In  addition  to  the  administration  of  the  remedy 
in  the  ordinary  way,  I  apply  the  1st  or  2d  decimal  dilution 
directly  to  the  cedematous  parts. 

Dr.  Holcombe  says  that  Arsenicum  album  is  indicated 
when  the  disease  is  a  genuine  anasarca,  coming  on  slowly  in 
the  chronic  diseases  of  broken  down  constitutions,  especially 
if  there  is  concomitant  cardiac  or  aortic  lesion,  Bright's 
disease  of  the  kidneys,  anaemia  or  dropsy.  Though  this 
remedy  is  also  recommended  by  Raue,  I  have  never  seen  the 
results  that  one  might  expect,  even  when  it  seemed  well 
indicated.  Holcombe  recommends  it  from  the  3d  to  the 
30th  dilution. 

Raue  and  Holcombe  both  suggest  Lachesis,  and  Baehr 
points  out  that  it  specially  has  the  peculiar  serous  infiltration 
of  internal  as  well  as  external  parts  of  the  body,  which  sets 
in  without  any  symptons  that  might  properly  be  called 
inflammatory,  and  which  reaches  its  full  development  in 
a  few  hours.      I  have  had  no  experience  with  Lachesis. 

Baehr  says  "Spongia  is  the  principal  remedy  for  the  so-called 
catarrhal  croup  with  distinct  symptoms  of  cedema  of  the 
mucous  lining  of  the  glottis,"    and  the  same  distinguished 


ACUTE    (EDEMATOUS     LARYNGITIS.  I49 

writer  .remarks  that  another  remedy  which  offers  some  resem- 
blance is  Phosphorus  ;  in  this  case,  however,  the  resemblance 
is  limited  to  a  single  symptom.  Holcombe  thinks  that  Chel- 
idonium  has  "  some  pathogenetic  resemblance  to  many 
symptoms  of  this  formidable  disease,"  and  Rhus  toxicoden- 
dron is  suggested  by  Baehr  as  acting  similarly  to  the  general 
disease,  but,  so  far,  these  recommendations  have  not  been 
acted  on.  Raue  thinks  that  China  and  Stramonium  are, 
perhaps,  the  most  important  remedies,  and  that  the  first- 
named  remedy  would  be  of  special  value  when  the  oedema 
is  a  so-called  pure  dropsy,  and  he  further  suggests  Arum 
triphyllum,  of  which  I  have  had  no  experience. 

But  let  us  suppose  that  in  a  case  of  undoubted  oedematous 
laryngitis,  the  patient  gets  rapidly  worse  in  spite  of  the  best 
selected  remedies,  or  that  the  disease  was  far  advanced 
before  medical  assistance  was  called.  What  will  the  physi- 
cian do  in  either  of  these  contingencies?  Will  he  permit  his 
patient  to  die,  or  will  he  make  an  effort  to  remove  the 
mechanical  obstacle  which  impedes  respiration  ?  It  appears 
to  me  that  no  conscientious  physician  of  our  school  could 
possibly  ignore  surgical  procedures,  even  if  they  had  not 
been  advised  by  Hughes  and  Hartlaub.  B?ehr,  too,  says 
that  "'  since  in  this  disease  we  cannot  fall  back  upon  experi 
ence  for  a  positive  knowledge  of  the  curative  action  of  drugs, 
it  would  be  criminally  indiscreet  to  depend  exclusively  upon 
internal  treatment."  Holcombe,  of  New  Orleans,  teaches 
that  scarification  of  the  infiltrated  tissues  is  of  immense 
benefit  when  it  can  be  thoroughly  done,  and  he  adds  that 
"  tracheotomy  is  the  last,  but  frequently  imperative  resort." 
The  surgical  procedures  are  two  in  number — scarification 
and  tracheotomy — the  former  of  use  in  the  supra-glottic 
form,  the  latter  in  the  sub-glottic  variety.  To  M.  Lisfranc 
is  due  the  credit  of  introducing  scarification  ;  Dr.  G.  Buck, 
of  New  York,  revived  the  operation,  and  it  has  been  still 
further  improved  by  Sir  George  Duncan  Gibb.  It  is  recom- 
mended by  all  the  best  authors,  Sestier,  Valleix,  von 
•  Riemssen,  though  Mackenzie  says  doubtfully  that    "  scarifi- 


150  \ci    I  i:    CE  ui.m  VTOTJS    LARYNGITIS. 

cation  Is  often  successful  when  the  disease  is  circumscribed." 
In  sonic  few  cases  the  laryngeal  mirror  may  be  employed, 
but  in  most   cases  the  practitioner  must  be  guided  by    the 

sensation  of  the  finger.  Mackenzie's  laryngeal  lancet  is 
decidedly  the  best  and  safest  instrument,  though  Buck's 
laryngeal  knife  is  little  inferior,  and  a  common  bistoury, 
wrapped  with  sticking-plaster  almost  to  the  point,  is  a  good 
instrument  in  good  hands.  The  older  surgeons  advised 
numerous  small  incisions,  but  von  Reimssen  recommends  the 
operator  to  make  several  long  incisions,  whereupon  the 
swelling  generally  collapses  at  once.  Trousseau  confesses 
that  he  has  not  had  the  courage  to  practice  this  operation 
and  he  considers  that  Buck  has  exaggerated  both  its  utility 
and  facility.  Legroux  recommended  that  the  cedematous 
swelling  be  lacerated  by  the  nail  of  the  index-finger  cut  to  a 
sharp  point,  but  it  is  doubtful  if  the  advice  has  ever  been 
acted  on.  After  the  operation,  warm  gargles  or  the  inhala- 
tion of  the  steam  of  hot  water  will  encourage  the  evacuation 
of  serum.  Sir  G.  D.  Gibb  recommends  the  introduction  of  a 
suitably  curved  bougie,  half  an  inch  in  diameter,  into  the 
larynx,  for  the  purpose  of  squeezing  out  the  serum  through 
the  punctures  made  by  scarification,  but,  though  this  would 
be  easy  in  adults,  it  would  be  difficult  in  children. 

We  have  a  great  consensus  of  the  authorities  as  to  the 
value  of  tracheotomy  in  this  disease,  and  here  the  homoeo- 
pathic writers,  Baehr  and  Ilolcombe,  are  one  with  Trousseau, 
von  Riemsscn  and  Mackenzie,  all  the  great  lights  of  the 
other  school  of  thought.  Baehr  says  that  in  this  disease, 
much  sooner  than  in  croup,  success  may  be  expected  from 
tracheotomy,  for  the  reason  that  the  trachea  is  not  usually 
involved,  while  von  Riemsscn  '  urges  that  we  must  bear  in 
mind,  as  a  general  rule,  that  in  severe  cases  the  danger  to  the 
life  of  the  patient,  if  the  physician  maintains  an  expectant 
attitude,  as  uncommonly  great,  and  that  even  postponing 
tracheotomy  for  a  few  hours  may  be  destructive  of  the 
patient,  if  the  physician  leaves  him  in  the  meantime,  and  he 
further  points  out  that  there  is  no  estimating  the  rapidity 


ACUTE    (EDEMATOUS    LARYNGITIS.  1 5 1 

with  which  stenosis  of  the  glottis  may  advance.  "We 
should  make  it  a  rule,  under  no  circumstances  to  leave  a 
patient  with  laryngeal  oedema,  and,  if  the  instruments  are 
not  at  hand  in  time,  to  perform  tracheotomy  with  a  penknife 
rather  than  let  the  patient  suffocate.  This  was  done  by  a 
physician  with  whom  I  am  acquainted,  who  on  making  a 
journey  across  country  on  the  island  of  Riigen,  and,  being 
called  into  a  farm-house  to  see  a  patient  with  oedema  of  the 
glottis,  found  himself  without  even  a  pocket-case.  The 
instance  which  Stannus  J.  Hughes  narrates  is  also  a  very 
pretty  illustration  of  this.  A  student  of  medicine  saved  a 
man,  who  was  at  the  point  of  suffocation  from  oedema  of  the 
glottis,  by  cutting  through  the  crico-thyroid  membrane  with 
his  penknife,  and  introducing  the  tube  of  his  penholder  as  a 
canula  (von  Riemssen). 

But  tracheotomy  should  not  be  delayed  till  the  patient  is 
all  but  moribund,  and  it  should  be  persisted  in,  as  Durham 
points  out,  even  though  the  difficulties  attending  the  opera- 
tion are  great  and  the  chances  of  a  successful  result  appear 
small.  If  the  suffocative  paroxysms  are  severe,  if  they 
follow  each  other  rapidly,  if  the  difficulty  of  breathing  in 
the  intervals  of  the  seizures  is  considerable,  then  the  opera- 
tion should  be  performed  at  once,  especially  if  the  slightest 
signs  of  poisoning  by  carbonic  acid  manifest  themselves.  It 
is  in  the  child  a  comparatively  simple  operation,  and,  while 
it  may  be  the  means  of  saving  life,  it  never  can  be  the  cause 
of  death.  Professor  Wood  remarks  that  well-authenticated 
cases  are  on  record,  in  which  patients  have  been  restored 
after  respiration  had  ceased,  and  the  pulse  could  be  no  longer 
felt  at  the  wrist.  One  would  think  that  chloroform  would 
be  exceedingly  unsafe,  but  experience  proves  that  it  is  not 
so,  and  it  would  be  almost  impossible  to  operate  on  young 
children  without  it.  The  patient  should  be  placed  on  a 
lounge  with  a  cushion  behind  the  neck  and  shoulders,  so  that 
the  head  is  thrown  back  and  the  trachea  is  well  forward. 
With  lamp-black  or  a  piece  of  charcoal  the  operator  should 
trace  on  the  skin  the  outline  of  the   incision  he  proposes  to 


•\t  i    ii     CEDEMATOUS    I  ,\u\  \t;i  lis. 

make  The  skin  is  then  raised  and  cut  through,  next  the 
muscles  are  carefully  incised  and  retracted  with  a  hook  on 
each  side.  The  wound  should  l)i-  sponged  before  each  cut 
with  the  bistoury,  and  all  haemorrhage  should  be  arrested 
before  the  trachea  is  opened.  When  the  white  rings  of  the 
trachea  are  exposed,  a  small  puncture  should  he  made  in 
them,  which  should  be  enlarged  with  a  probe-pointed 
bistoury  till  the  orifice  is  say  three-quarters  of  an  inch  in 
length,  and  it  is  important  to  note  that  the  trachea  must  be 
cut  exactly  in  the  middle  line.  A  double  canula  should  then 
be  placed  in  the  wound  by  means  of  a  dilator,  and  the  canula 
should  be  secured  by  means  of  tapes  fastened  behind  the 
neck.  Bretonneau  lays  clown  the  practical  rule  that  the 
canula  should  always  be  at  least  of  the  diameter  of  the 
glottis  of  the  subject.  After  the  operation,  the  patient 
should  be  enveloped  in  a  warm  and  moist  atmosphere,  but, 
at  the  same  time,  ventilation  must  be  maintained.  Then, 
well-selected  remedies  should  be  administered  with  the  view 
of  acting  on  the  cedematous  parts.  For  fuller  particulars  on 
tracheotomy,  I  would  refer  the  reader  to  the  very  able  article 
on  that  subject  by  Arthur  E.  Durham,  Assistant  Surgeon  to 
Guy's  Hospital,  in  Holmes'  System  of  Surgery,  or  the  article 
in  the  Internation  Encyclopaedia  of  Surgery. 

Mackenzie  says  that  ice  should  be  "  uninterruptedly  swal- 
lowed," and  Holcombe  has  found  it  beneficial ;  von  Niemeyer 
relates  that  under  this  treatment  he  once  witnessed  the 
recovery  of  one  of  his  colleagues,  in  whom  suffocation 
seemed  so  imminent  that  the  medical  attendants  hardly 
dared  to  defer  tracheotomy. 

Aphorisms. 

r.  Acute  cedematous  laryngitis  .is  not  common  in  children, 
simply  because  in  children  the  larynx  is  scantily  supplied 
with  sub-mucous  areolar  tissue. 

2.  The  older  writers  held  that  this  disease  was  non-inflam- 
matory, but  later  observers   have   conclusively  shown    that 


ACUTE    (EDEMATOUS    LARYNGITIS.  1 53 

inflammatory  oedema  of  the  larynx  is  much  more  frequent 
than  non-inflammatory  infiltration. 

3.  Acute  (edematous  laryngitis  is  very  like  croup,  but  in 
the  first-named  disease  dyspnoea  is  greatest  on  inspiration, 
while  expiration  is  comparatively  free,  but  in  all  the  croups, 
inspiration  is  as  difficult  as  expiration. 

4.  Formerly  it  was  believed  that  the  effusion  of  sub-glottic 
cedematous  laryngitis  was  invariably  fibrinous,  but  it  is  now 
quite  certain  that  it  is  often  serous. 

5.  Acute  cedematous  laryngitis  is  a  very  fatal  disease, 
Sestier  reporting  158  deaths  in  213  cases,  though  trache- 
otomy was  performed  in  30  of  the  fatal  cases. 

6.  Acute  cedematous  laryngitis  originating  in  the  larynx 
itself  is  almost  invariably  fatal. 

7.  The  leading  homoeopathic  remedies  are  Apis  mellifica, 
Sanguinaria,  Aconite,  Iodium,  Arsenicum  album,  Lachesis 
and  Spongia.  Minor  remedies  are  Phosphorus,  China  and 
Rhus  toxicodendron. 

8.  As  a  last  resort,  scarification  is  of  great  value  in  the 
supra-glottic  variety,  and  tracheotomy  in  both  supra-glottic 
and  sub-glottic  forms  of  the  disease. 

9.  Durham  urges  that  tracheotomy  should  be  persisted  in, 
even  though  the  difficulties  attending  the  operation  are 
great,  and  the  chances  of  a  successfnl  issue  appear  small. 

10.  Mackenzie,  Holcombe  and  von  Niemeyer  all  strongly 
advise  the  uninterrupted  swallowing  of  small  pills  of  ice. 


CHAPTER  VII. 


Spasmodic    Croi   p. 


Croup  is  one  of  the  most  dreaded  of  infantile  diseases, 
and  it  is  also  one  of  the  least  understood.  There  are  two 
varieties  of  croup  proper,  the  spasmodic  and  the  pseudo- 
membranous, the  first  a  severe  but  comparatively  inocuous 
disease,  the  second  apparently  less  severe  but  in  reality  one 
of  the  most  terrible  of  maladies.  Rut  it  must  be  distinctly 
understood  that  while  distinct  types  of  these  maladies  exist, 
that  frequently  they  shade  off  and  run  into  each  other  in 
such  a  manner  that  even  the  most  experienced  physicians 
are,  at  times,  perplexed.  A  case  will  commence  as  spasmodic 
croup  and  apparently  be  progressing  finely;  when  the  dreaded 
pseudo-membranous  complication  makes  its  appearance,  and 
soon  the  patient  is  hopeless.  Or  a  child  will  have  repeated 
attacks  of  spasmodic  croup,  recovering  from  each  attack 
after  a  good  deal  of  suffering;  long  success  lulls  the  watch- 
fulness of  the  mother,  and  at  length  an  attack  assumes  the 
pseudo-membranous  form,  and  being  met  by  unsuitable 
treatment,  it  soon  proves  fatal.  The  name  of  croup  conveys 
very  different  ideas  to  different  minds,  and  a  case  which  one 
physician  dignifies  with  that  title  appears  to  another 
altogether  beneath  his  notice.  Many  years  ago  I  was  visiting 
a  physician,  and  as  we  sat  gossiping  in  his  office,  he  suddenly 
remarked  that  he  must  go  and  see  a  case  of  croup.  Having 
been  accustomed  to  see  severe  forms  of  the  disease,  I  started 
up,  seized  my  hat,  and  made  ready  for  a  rapid  march.  My 
friend  remarked  that  there  was  no  need  of  haste,  and  so, 
after  a  very  leisurely  walk,  we  came  to  the  house.  Ushered 
into  the  parlor,  we  found  a  couple  of  ladies  sewing  and 
chatting,  and  two  or  three  children  playing  on  the  floor,  but, 


SPASMODIC    CROUP.  1 55 

to  me,  no  signs  of  a  croup  patient.  My  friend,  however, 
called  a  little  child  from  its  play  and  auscultated  its  larynx 
carefully,  requesting  me  to  do  the  same.  I  did  so,  and  after 
a  careful  examination  I  found  that  the  child  had  a  very 
slight  cooing  in  the  larynx,  but  no  cough,  no  hoarseness,  no 
fever,  no  croup. 

Like  some  other  infantile  diseases,  spasmodic  croup  has 
been  burdened  with  a  multiplicity  of  names.  It  has  been 
called  false  croup  and  pseudo-croup  in  contradistinction  to 
true  croup,  commonly  called  pseudo-membranous  croup. 
Guersant  calls  it  stridulous  laryngitis  ;  Bretonneau  names  it 
stridulous  angina  ;  while  Millar  and  Simpson  speak  of  it  as 
the  acute  asthma  of  infants.  Cullen's  name,  "cynanche 
trachealis,"  is  wholly  wrong,  as  it  directly  leads  to  erroneous 
ideas  as  to  the  site  of  the  disease,  and  Morell  Mackenzie,  the 
latest  writer  on  laryngeal  diseases,  gives  spasmodic  croup  as 
one  of  the  synonyms  of  spasm  of  the  glottis.  The  French 
writers,  Rilliet  and  Barthez,  and  the  American  writers,  Meigs 
and  Pepper,  concur  in  calling  it  spasmodic  laryngitis,  while 
Professor  Wood  calls  it  catarrhal  croup,  Wichmann,  Michaelis 
and  Double  style  it  spasmodic  croup,  and  I  prefer  that  name, 
as  it  appears  to  me  that  the  laryngeal  spasm  is  the  essential 
feature  of  the  disease,  while  the  catarrhal  symptoms  are  less 
characteristic  ;  but  it  is  well  to  bear  in  mind  the  fact  that 
severe  catarrhal  or  even  frankly  inflammatory  symptoms  may 
arise  in  the  course  of  the  disease,  calling  for  modifications  in 
treatment. 

Spasmodic  croup,  then,  may  be  defined  to  be  a  laryngeal 
disease  almost  peculiar  to  infancy,  consisting  of  a  violent 
spasm  of  the  interior  muscles  of  the  larynx,  combined  with 
a  catarrhal  inflammation  of  the  adjacent  mucous  membrane, 
but  without  pseudo  membranous  exudation  ;  this  combina- 
tion of  laryngeal  spasm  with  catarrhal  inflammation  causing 
important  changes  in  the  respiration  and  in  the  voice. 
There  are  thus  several  elements  in  the  disease,  for  the 
nervous  system  is  involved  as  well  as  the  vascular,  so  that 
spasmodic  croup  is  allied  to  the  neuroses  as  well  as  to  the 


15''  SPASMODIC    CROUP. 

inflammations.  At  times  thecatarrhal  inflammation  is  quite 
trifling,  while  the  spasmodic  action  is  distinctly  marked,  or 
the  inflammatory  action  may  be  very  severe,  with  very  little 
laryngeal  spasm,  in  which  case  the  disease  would  approxi- 
mate to  catarrhal  laryngitis.  "The  spasm  of  the  laryngeal 
sphincter  seems  to  be  the  result  of  a  disordered  action  of  the 
excito-motor  innervation  of  the  part,  the  irritant,  which  is 
productive  of  the  morbid  innervation,  being,  in  all  proba- 
bility, the  inflammation  of  the  laryngeal  mucous  membrane, 
which,  as  has  been  already  stated,  constitutes  one  element  of 
the  malady.  The  nervous  element  predominates  in  the 
earl)'  part  of  the  attack,  but  towards  the  conclusion  the 
spasmodic  symptoms  disappear  entirely,  and  we  have  left 
only  those  which  depend  on  the  local  tissue  changes." 
(Meigs  and  Pepper.)  Dr.  Copland  writes:  "The  experi- 
ments of  Schwilgue,  Jurine,  Albers,  Schmidt  and  Chaussier, 
as  well  as  pathological  observation,  prove  that  the  form  of 
disease  called  false  croup  by  the  above  authors  pro- 
ceeds from  a  similar  state  of  morbid  action  as  that 
denominated  the  pure  disease  (pseudo  membranous  croup), 
and  is  merely  a  modification  resulting  from  less  intensity  of 
the  inflammation,  peculiarity  of  the  temperament  and  habit 
of  body,  the  causes  occasioning  it,  and  the  greater  predomi- 
nance of  the  spasmodic  or  nervous  states."  This  is  decidedly 
erroneous,  for  spasmodic  croup  differs  radically  from 
pseudo-membranous  croup,  and  I  hold  with  Meigs  and 
Pepper  that  they  are  distinct  affections,  which  may,  in  the 
great  majority  of  cases,  be  distinguished  from  each  other  at 
a  very  early  stage  by  a  casual  observer.  I  concede,  of  course, 
that  pseudo-membranous  croup  may  be  developed  in  the 
course  of  spasmodic  croup,  and  the  practical  physician  must 
never  forget  the  pregnant  words  of  Rindfleisch,  "  the  devel- 
opment of  a  false  membrane  is  connected  in  the  closest  man- 
ner with  the  catarrhal  state,  and  constitutes  an  anatomical 
acme  of  the  morbid  process.'  At  one  end  of  the  scale  you 
have  a  mild  form  of  the  disease,  differing  from  catarrhal 
laryngitis  only  in  the  presence  of  a  slight  degree  of  laryngeal 


SPASMODIC    CROUP.  157 

spasm  ;  at  the  other  end  you  have  a  severe  type  resembling 
pseudo-membranous  croup  so  closely  as  to  try  the  acumen 
of  the  keenest  observer.  Yet  the  distinction  between  the 
worst  case  of  spasmodic  croup  and  even  the  very  mildest 
case  of  pseudo-membranous  croup  is  of  vast  moment  to  the 
patient,  since  the  prognosis  is  so  widely  different  in  these 
two  diseases. 

Spasmodic  croup  appears  to  be  more  frequent  on  this 
continent  than  the  pseudo  membranous  variety,  while  the 
contrary  seems  to  be  the  case  in  Europe.  For  one  case  of 
the  pseudo-membranous  we  meet  with  at  least  ten  of  the 
spasmodic  ;  hence,  while  with  us  in  all  varieties  of  croup 
massed  together  the  mortality  is  comparatively  small, 
European  writers  state  that  almost  one-half  of  those  attacked 
die.  Spasmodic  croup,  again,  is,  generally  speaking,  a 
disease  of  infancy  and  early  childhood,  while  pseudo-mem- 
branous croup  often  attacks  those  of  maturer  years. 

In  common  with  the  more  dangerous  form  of  croup, 
spasmodic  croup  affects  male  children  more  frequently  than 
female,  even  when  the  same  care  is  taken  of  the  patients,  a 
circumstance  of  which  no  adequate  explanation  has  yet  been 
given.  Out  of  a  hundred  cases,  sixty  will  occur  in  boys  and 
forty  in  girls,  and  this  observation  has  been  repeatedly  con- 
firmed. It  is  most  frequent  in  fall  and  winter,  and  also  in 
spring  when  winter  is  breaking  up,  and  it  is  rarely  seen  in 
summer.  As  a  general  rule  spasmodic  croup  is  prone  to 
appear  on  the  banks  of  lakes  and  in  the  vicinity  of  large 
bodies  of  water. 

Spasmodic  croup  is  essentially  a  disease  of  infancy  and 
childhood.  Guersant  says  that  it  occurs  most  frequently 
between  the  ages  of  two  and  seven  ;  J.  Lewis  Smith  thinks 
that  it  ordinarily  occurs  between  the  ages  of  two  and  five  ; 
Condie  has  met  with  it  in  children  of  nine  or  ten  months, 
but  less  frequently  than  in  those  between  two  and  eight 
years.  Meigs  and  Pepper  state  that  "it  occurs  most 
frequently  during  the  period  of  the  first  dentition,  being 
more  common  in  the  second  year  of  life,  which  is  the  time 


I  3S  SPASMODIC    CROUP. 

of  the  greatest  activity  of  the  first  dentition,  than  at  any 
other  age,  though  it  is  often  met  with  in  the  third  and  fourth 
years."  Rilliet  and  Barthez  are  of  opinion  th.it  it  is  most 
common  between  the  ages  of  three  and  five,  thus  omitting 
the  very  year,  the  second,  in  which  it  is  most  frequently 
seen.  A  few  of  my  cases,  not  more  than  eight  or  ten  per 
cent,  of  the  whole  number,  occurred  during  the  first  year  of 
life  ;  at  least  a  third  of  the  whole  number  were  in  the  second 
year;  and  a  somewhat  smaller  proportion,  say  one-fifth,  were 
in  the  third  year,  after  which  they  decreased,  till  in  the 
seventh  and  eighth  years  very  few  cases  were  seen. 

Spasmodic  croup  is  a  sporadic  disease,  in  which  respect  it 
differs  from  pseudo-membranous  croup,  which  is  occasionally 
epidemic.  Rilliet  and  Barthez,  however,  state  that  "  it  is 
incontestable  that  it  may  prevail  epidemically,"  but  this 
opinion  is  based  not  on  their  own  observations,  but  on  those 
of  J  urine,  of  Geneva,  who  describes  an  epidemic  which 
raged  in  that  city  in  1808.  My  own  opinion  is  that  the 
so-called  epidemics  of  this  disease  depend  upon  certain 
conditions  of  the  atmosphere  exciting  the  morbid  state  to 
an  unusual  degree,  and  that  it  is  never  epidemic  like  whooping 
cough  or  even  pseudo-membranous  croup.  Again,  the  disease 
is  hereditary  in  certain  families,  and  almost  every  physician 
of  experience  can  call  to  mind  families  in  which  it  has 
prevailed  generation  after  generation.  Dr.  J.  F.  Meigs,  of 
Philadelphia,  remarks,  "  I  am  acquainted  with  one  family  in 
this  city  in  which  the  children  for  three  generations  were 
extremely  liable  to  it;  with  another,  in  which  the  grand- 
mother and  grand-children  were  frequently  attacked  ;  and 
with  a  third  in  which  the  father  and  children  showed  the 
same  predisposition  in  the  most  marked  manner." 

This  'disease  occurs  alike  in  the  robust  and  in  the  weak, 
and  many  children  are  predisposed  to  it  when  laboring  under 
any  digestive  derangement.  The  most  important  exciting 
cause  is  exposure  to  cold,  either  sudden  transitions  from 
heat  to  cold  or  exposure  in  the  open  air.  Narrowness  of  the 
rima  glottidis  is  at  times  a  predisposing  cause,  and  nervous 


SPASMODIC    CROUP.  1 59 

children  are  at  all  times  most  likely  to  be  attacked.  Dr.  J. 
Lewis  Smith  has  observed  that  this  disease  is  not  uncommon 
at  the  commencement  of  measles,  and  Dr.  Condie  notes  that 
after  an  attack  has  once  happened,  the  occurrence  of  any 
sudden  or  violent  mental  emotion  is  liable  to  excite  a 
paroxysm. 

It  is  characteristic  of  spasmodic  croup  to  attack  suddenly 
and  without  warning ;  as  old  Dr.  Meigs  quaintly  puts  it, 
"  there  is  often  not  the  least  reason  to  suppose  the  child  sick 
until  the  moment  of  explosion  of  the  attack,  an  attack  which 
in  many  examples  is  more  violent  in  the  first  moment  of  its 
existence  than  in  any  subsquent  time."  In  a  considerable 
number  of  cases  the  attack  is  preceded  by  a  paroxysm  of 
teething  fever,  and  so  close  is  the  connection  between  the 
fever  of  dentition  and  spasmodic  croup  that  Dr.  Copland 
affirms,  "  I  have  scarcely  ever  seen  a  well-defined  case  uncon- 
nected with  dentition."  In  a  much  larger  number  of  cases 
there  is  slight  coryza  with  hoarse  cough.  Now,  hoarseness 
excites  little  attention  in  adults,  as  in  acute  cases  is  does  not 
usually  indicate  any  special  degree  of  danger,  yet  the 
contrary  is  the  case  with  children,  as  with  them  hoarseness 
ahvays  indicates  danger,  and  it  should  never  be  neglected. 
The  first  paroxysm  generally  takes  place  in  the  night  during 
the  first  sleep,  between  ten  o'clock  and  midnight.  Out  of  a 
hundred  cases  ninety  five  will  occur  in  the  night,  and  the 
remaining  five  in  the  afternoon,  and  three-fourths  of  the 
night  cases  will  take  place  before  midnight,  and  the 
remaining  fourth  after  that  hour.  With  or  without,  then, 
any  premonitory  symptoms,  the  child  is  attacked  by  a  dry, 
ringing  clangorous  cough,  which  has  been  compared  to  the 
notes  of  a  trumpet  mingled  with  the  rasping  of  a  large  saw, 
but  which,  as  Professor  Wood  remarks,  "  is,  in  fact,  compar- 
able to  nothing  else  in  nature,  and  to  be  appreciated  only  by 
being  heard."  This  sonorous  and  barking  cough  is  accom- 
panied by  prolonged  inspiration,  by  a  shrill  and  rasping 
sound,  and  by  rapid  and  irregular  respiration.  At  times  the 
breathing  is  so  very  irregular  that  suffocation  appears  to  be 


160  SPASMODIC    CROUP. 

impending,  and  the  child  tosses  about  in  its  bed  as  if  fighting 
for  air.  The  characteristic  cough  is,  according  to  Wood, 
occasioned,  in  all  probability,  by  a  certain  spasmodic  rigidity 
of  the  vocal  cords,  giving  an  almost  metallic  tension  to  the 
sides  of  the  rima  glottidis.  The  voice  is  hoarse  and  rough, 
though  rarely  suppressed,  and  then  only  for  a  brief  period — 
this  is  one  of  the  most  salient  points  of  difference  between 
the  disease  under  consideration  and  pseudo-membranous 
croup.  There  is  but  little  real  pain  in  the  larynx  or  trachea, 
but  a  feeling  of  constriction  which  seems  to  be  still  less 
endurable  than  pain.  The  little  patient  may  endure  the 
attack  for  a  little  time  with  considerable  fortitude,  but  soon 
he  sits  up  in  bed  gasping  for  breath,  or  lies  on  his  back  with 
his  neck  stretched  to  the  utmost,  while  the  throat  is  grasped 
by  the  hands  as  if  to  remove  some  obstacle  to  respiration. 
If  able  to  speak,  he  complains  of  pain  and  tightness  at  the 
throat,  while  the  face  has  an  anxious  and  troubled  expres- 
sion. He  becomes  greatly  agitated,  cries  violently  between 
the  fits  of  coughing,  and  begs  piteously  for  help.  When  the 
paroxysm  first  comes  on  the  face  is  flushed,  the  skin  warm, 
and  the  pulse  strong  and  frequent,  but  as  the  attack  becomes 
more  intense  the  face  becomes  of  a  livid  hue,  while  the 
extremities  are  cool  and  the  pulse  frequent,  feeble  and 
fluttering.  Copland  says  that  "  there  is  little  or  no  increase 
of  animal  heat  or  fever,"  but  fever  was  present  in  the  vast 
majority  of  my  cases,  and  there  is  a  striking  consensus  of 
opinion  on  this  point.  After  lasting  from  twenty  minutes  to 
an  hour,  or  even  two  hours  or  more,  the  breathing  becomes 
easier,  the  cough  less  frequent  and  less  clangorous,  and  the 
sawing  sound  is  only  heard  when  the  little  patient  cries. 
Often  as  soon  as  relief  is  obtained,  the  child  falls  into  a 
sweet  sleep.  In  the  morning  he  seems  nearly  well,  having 
only  an  occasional  croupy  cough,  with  hoarseness  of  the  voice 
and  redness  of  the  fauces.  At  times  this  croupous  cough 
continues  for  several  days,  gradually  getting  milder  and  less 
frequent,  till  at  last  it  ceases  entirely.  When  the  attack 
occurs  early  in    the    night,  it  is  likely  to  be  followed  by  a 


SPASMODIC    CROUP.  16l 

second  milder  attack  towards  morning  ;  as  the  second  evening 
approaches,  the  patient  is  the  subject  of  a. similar  paroxysm 
of  varying  severity.  Professor  Wood  says  that  the  symp- 
toms are  often  more  violent  than  at  first ;  Dr.  J.  F.  Meigs 
says  that,  as  a  general  rule,  the  first  attack  is  the  most  severe. 
So  far  as  my  observation  extends,  I  have  noted  that  while 
the  paroxysm  is  more  prolonged  and  more  exhausting,  the 
symptoms  appear  to  be  less  severe. 

This  may  be  taken  as  a  fair  account  of  a  case  of  moderate 
severity,  but  at  times  the  laryngeal  inflammation  is  more 
intense  and  apparently  involves  a  larger  extent  of  the  mucous 
membrane.  The  cough  is  hoarser  and  more  frequent,  the 
respiration  more  difficult,  the  fever  more  pronounced,  and 
this  state  is  developed,  as  a  general  rule,  earlier  in  the  night 
than  the  milder  form  of  the  disease.  As  the  night  advances 
all  the  symptoms  intensify,  till  actual  suffocation  is  threat- 
ened. Towards  morning  amelioration  takes  place,  the  fever 
declines,  the  breathing  becomes  easier,  the  cough  looser,  the 
stridulous  sound  less  marked.  .  But  as  the  next  evening 
approaches,  all  the  symptoms  reappear,  to  be  followed  by 
another  remission  during  the  day,  which,  in  its  turn,  is 
followed  by  another  night  attack,  and  so  on,  for  several  days. 
I  have  attended  a  number  of  cases  in  which  the  daily  remis- 
sion hardly  existed,  for  the  disease  continued  day  and  night, 
for  three  or  four  days.  If  no  fortunate  change  is  brought 
about  by  treatment,  the  breathing  becomes  more  and  more 
difficult,  the  cough  rarer  and  more  feeble,  and  is  finally  sup- 
pressed altogether,  the  voice  is  hardly  audible,  the  pulse  is 
small  and  rapid,  the  face  pale  and  cool,  with  pinched  and 
contrasted  features.  Finally  the  child  becomes  comatose, 
and  death  takes  place  from  asphyxia,  often  with  general 
convulsions.  In  favorable  cases  the  fever  declines,  the 
voice  becomes  stronger,  the  cough  looser,  the  stridor  dimin- 
ishes, and  the  patient  rapidly  enters  on  convalescence. 
These  severe  cases  last  longer  than  those  of  the  milder  type. 
A  severe  case  will  keep  the  patient  in  real  danger  for  two, 
three,  or  even  four  days,  while  the  milder  cases  subside  after 


[62  SPASMODIC     CROUP. 

forty-eight  hours,  the  patient  rarely  being  in  real  clanger. 
In  severe  cases  the  disease  is  often  followed  by  hoarse  cough 
with  husk}-  breathing,  and  this  state  is  sometimes  difficult  of 
cure.  The  disease  is  very  likely  to  return,  and  paroxysms 
more  frequently  come  on  at  intervals  of  from  six  to  twelve 
months  than  in  a  shorter  period,  though  I  have  attended 
patients  who  have  had  five  or  six  attacks  in  a  year. 

Auscultation  of  the  larynx  should  never  be  neglected,  and 
for  this  purpose  I  now  prefer  the  single  stethoscope  to  the 
double  one.  On  auscultation  it  will  be  found  that  the 
respiration  is  dry  and  wheezing,  with  a  hissing,  sonorous 
sound,  as  if  the  larynx  were  narrower  than  usual,  and  had 
rigid  and  unyielding  walls.  It  is  well  to  bear  in  mind  the 
remark  of  M.  Trousseau,  that  the  hoarse-sounding,  croupal 
cough  is  not  a  sign  of  exudation  in  the  larynx,  but  rather  of 
its  absence. 

Spasmodic  croup  is  rarely  fatal,  so  that  we  arc  not  so 
conversant  with  its  morbid  anatomy  as  we  are  with  that  of 
the  more  formidable  pseudo-membranous  croup,  and  many  of 
the  post-mortem  changes  are  wholly  inadequate  to  account 
for  the  fatal  result.  The  pathological  state  present  is  slight 
inflammatory  hyperaemia,  with  perhaps  increased  activity  of 
the  mucous  follicles.  Very  severe  cases  have  redness  of  the 
larynx,  extending  to  the  trachea,  or  even  to  the  bronchi,  and 
this  redness  may  either  be  continuous  or  in  patches.  There 
is  usually  a  slight  swelling  of  the  sub-mucous  tissue,  with 
viscid  and  adherent  mucus  if  death  has  taken  place  at  an 
early  stage  of  the  disease,  or  with  more  abundant  and  puru- 
lent mucus  if  the  disease  proved  fatal  at  a  later  period. 
Many  have  supposed  that  death  often  takes  place  from  a 
literal  occlusion  of  the  larynx;  but  this  is  very  seldom  the 
case,  for,  in  a  vast  majority  of  cases  the  larynx  is  sufficiently 
open  for  the  purpose  of  respiration,  and  we  conclude  that 
many  patients  are  asphyxiated  by  spasmodic  contraction  of 
the  laryngeal  muscles.  "In  some  rare  instances,  no  signs  of 
disease  are  discovered  in  the  mucous  membrane,  and  the 
patient  has  probably  died  of  spasm,  consequent  upon  high 


SPASMODIC     CROUP.  163 

vascular  irritation  or  congestion,   the  marks  of  which  disap- 
pear with  life."  (Wood.) 

Almost  the  only  disease  with  which  spasmodic  croup  is 
likely  to  be  confounded  is  pseudo-membranous  croup,  and 
the  diagnosis  will  be  carefully  considered  in  the  next  chapter. 
It  may  also  be  mistaken  for  spasm  of  the  glottis  ;  the  diag- 
nosis will  be  found  in  the  chapter  on  that  disease. 

Spasmodic  croup  is  very  rarely  a  fatal  disease  under 
homoeopathic  treatment.  Still,  cases  which  have  been  badly 
managed  under  other  practitioners,  may  die  under  the  care 
of  an  homoeopathic  physician  ;  and  the  worst  kind  of  misman- 
agement consists  in  the  administration  of  violent  emetics 
for  the  purpose  of  "clearing  out  the  phlegm  and  breaking 
up  the  spasm,"  according  to  the  wont  of  our  allopathic 
step-brethren.  I  am  satisfied  that  the  irritant  action  of 
these  emetics  is  one  of  the  principal  means  whereby  mild 
cases  of  croup  are  converted  into  severe  ones.  Very  shrewd 
is  the  remark  of  Dn  J.  Lewis  Smith,  "  While  a  favorable 
opinion  in  reference  to  the  result  may  ordinarily  be  expressed, 
the  physician  should  not  forget  the  fact  that  death  may 
occur."  One  would  say  that  a  certain  amount  of  danger  is 
present  when  the  disease  lasts  longer  than  forty-eight  hours, 
and  that  the  danger  increases  with  the  prolongation  of  the 
disease.  When  the  paroxysms  diminish  in  intensity,  when  the 
fever  declines  and  the  cough  becomes  moist,  a  favorable  termi 
nation  may  confidently  be  expected.  On  the  other  hand, 
an  extremely  small  and  rapid  pulse  is  an  unfavorable  sign, 
especially  when  met  with  in  conjunction  with  coolness  of  the 
extremities;  a  marked  intensity  of  the  stridulous  sound, 
especially  in  the  expiration  ;  suppression  of  the  voice  and 
extreme  dyspnoea;  paleness  of  the  face  and  diminution  of 
strength  would  form  an  extremely  ominous  group  of  symp- 
toms. Should  convulsions  supervene  in  addition,  there 
would  remain  no  ground  for  hope. 

Dr.  Duncan,  of  Chicago,  accurately  remarks  that  "the 
treatment  of  spasmodic  croup  has  been  so  mixed  up  with 
that  of  membranous  croup  and  laryngitis  (simplex)  that  the 


i"|  SPASMODIC    CROUP. 

Literature  is  very  unsatisfactory,"  and  he  correctly  adds,  "the 
advice  ol  Benninghausen  to  give  Aconite,  Spongiaand  Hepar 
is  about  as  good  as  any  routine  treatment."  Aconite  is  one 
oi  the  leading  remedies  in  the  treatment  of  both  spasmodic 
and  pseudo-membranous  croup,  though  Dr.  Alphonse  Teste 
says  that  it  "  is  indicated  in  croup  in  the  rare  cases  of  violent 
fever  in  the  beginning;  from  the  moment  that  the  febrile 
symptoms  diminish  a  little,  or  when,  after  one  or  two  doses, 
it  seems  to  produce  no  effect,  it  should  be  discontinued,  and 
that  finally,  under  penalty  of  losing  precious  time,  when 
often  the  minutes  are  to  be  counted."  On  the  other  hand, 
Croseric  says  "the  first  medicine  to  employ  when  the  croup 
declares  itself  is  Aconite,"  and  Duncan  remarks  that  "Aconite- 
is  often  the  only  remedy  needed,  as  it  corresponds  to  the 
spasm,  the  restlessness,  the  anxiety  and  the  fever  that  arises." 
Aconite  is  indicated  when  the  patient  is  attacked  in  the 
evening  after  sleeping,  though  he  has  been  restless  and 
feverish  before  going  to  bed.  The  patient  has  great  nervous 
and  vascular  excitement,  with  restless  tossing  about  in  the 
bed.  On  attempting  to  swallow  he  complains  of  pain  in  the 
throat,  and  this  is  aggravated  during  deglutition,  though  it 
is  never  really  absent.  The  cough  is  dry,  hacking  and 
frequent,  and  it  follows  every  expiratory  effort,  but  is  absent 
during  inspiration.  Sometimes  the  patient  wants  to  cough, 
but  restrains  himself  on  account  of  the  pain.  The  cough, 
as  well  as  the  stridulous  sound,  is  distinctly  paroxysmal,  and 
it  is  characteristic  that  these  are  heard  only  during  inspira- 
tion. The  pulse  is  accelerated,  the  skin  dry  and  hot,  and  the 
patient  drinks  with  avidity.  "The  children  attacked  with 
this  form  of  croup  are  the  nervo-sanguinc  or  ncrvo-bilious, 
i.  e.,  the  nervous  active,  while  membranous  croup  attacks 
lymphatic  children  as  a  rule.  The  more  nervous  the  child 
the  longer  the  spasm  continues"  (Duncan).  In  mild  cases 
the  dilutions  will  suffice,  but  when  the  case  is  threatening  I 
put  two  or  three  drops  of  the  tincture  of  the  root  in  a 
tumbler  of  water,  and  give  a  teaspoonful  every  half  hour,  or 
even  every  fifteen  minutes. 


SPASMODIC     CR01    P.  165 

By  almost  universal  consent  Spongia  occupies  the  next 
place  to  Aconite  in  the  treatment  of  croup.  Dr.  Hughes 
says  that  "  the  two  Jeading  remedies  in  croup  are  Aconite 
and  Spongia."  while  Professor  Hempel  says  still  more  em- 
phatically that  "  in  this  disease  we  have  found  that  if 
Aconite  and  Spongia  leave  us  in  the  lurch,  the  chances  of 
recovery  are  very  slight  indeed."  On  the  other  hand,  Dr. 
Teste  says,  "  The  good  effects  of  Spongia  are  incontestable, 
bnt  they  have  been  exaggerated;  Spongia  belongs  to  the  first 
period.  I  do  not  use  it.''  Hahnemann  says  of  Spongia: 
"  Its  most  remarkable  therapeutic  virtue  is  to  cure  croup  ; 
among  other  symptoms  it  is  indicated  in  this  disease  by 
difficulty  in  breathing,  as  though  a  plug  had  lodged  in  the 
throat,  and  as  though  the  larynx  were  so  constricted  that 
breath  cannot  pass  through  it."  Hempel  recommends  it  to 
be  given  if  Aconite  produces  a  profuse,  warm  perspiration, 
and  the  spasmodic  breathing  still  continues.  In  the  croup 
of  Spongia  the  larynx  is  painful,  as  if  pressed,  with  a  burn- 
ing and  constrictive  sensation  in  the  organ  ;  respiration  is 
difficult,  as  if  a  plug  were  in  the  throat ;  it  is  wheezing, 
hissing  and  sawing,  and  at  intervals  there  are  suffocative  fits, 
during  which  the  child  is  unable  to  breathe  except  with  the 
head  bent  backwards  ;  the  cough  is  hollow  and  barking,  with 
difficult  expectoration  of  scanty  mucus  ;  coughing  causes  pain 
in  the  trachea  and  lungs.  Dr.  Paine,  of  Bath,  Maine, 
observes :  "  It  seems  that  Spongia  nearly  covers  the  same 
symptoms  as  Aconite,  with  this  difference  and  addition  :  in 
Spongia  croup  the  stridulous  respiratory  sound  is  always 
during  inspiration  and  the  cough  less  constant,  and  excited 
only  by  the  inspiratory  act  ;  and  the  cough  and  sibilant 
respiratory  sound  are  not  so  constantly  concurrent  as  the 
Aconite  croup.  There  is  also,  in  Spongia  croup,  fluent 
coryza,  and  sometimes  sneezing,  with  saliva  dribbling  from 
the  mouth,  which  we  do  not  see  in  Aconite  croup."  I 
remember  hearing  Dr.  Constantine  Hering  remark  that 
Spongia  has  aggravation  in  the  evening,  while  Hepar  has 
aggravation  in  the  morning.     The  cough  of  Spongia  is  piping, 


[66  SPASMODIC    CROUP. 

crowing,  and  of  a  very  dry  sound,  with  rough,  crowing  cry, 
and  sensitiveness  to  the  touch  ;  while  the  cougli  of  Hepar  is 
deep,  rough  and  barking  ;  hoarseness  or  aphonia,  with  slight 
suffocative  spasms ;  respiration  not  without  rattling  of 
mucus.  The  cough  of  Spongia  is  worse  when  sitting  erect  and 
better  in  the  horizontal  position,  while  the  cough  of  Hepar 
is  excited  by  lying  and  is  aggravated  by  lying  with  the  head 
low,  and  is  better  with  the  head  high-  The  cough  of  Spon- 
gia is  improved  by  eating  and  drinking,  while  the  cough  of 
Hepar  is  excited  by  cold  diet.  Hempel  recommends  the 
use  of  the  tincture.  I  have  always  used  the  2d  or  3d  deci- 
mal dilutions,  prepared  and  administered  in  the  same  manner 
as  Aconite. 

In  routine  practice — and  some  of  Hahnemann's  followers 
adhere  to  routine  as  abjectly  as  did  the  Esculapians  whom 
Hahnemann  scourged — it  is  customary  to  give  first  Aconite, 
then  Spongia ;  next,  "  if  that  don't  do,"  Hepar.  Even 
llartmann,  who  is  not  usually  a  routinier,  recommends 
Spongia  to  be  given  after  Aconite,  adding,  "in  twenty-four 
hours  the  danger  is  generally  over.  If,  after  this  lapse  of 
time,  the  cough  should  still  have  the  peculiar  croup  sound, 
the  breathing  should  still  be  hissing,  or  if  there  should  still 
be  danger  of  suffocation,  Hepar  is  then  to  be  employed. "' 
The  dry,  harsh,  deep  and  hollow  cough  of  Hepar  is  appar- 
ently caused  by  tickling  in  the  larynx  or  scraping  in  the 
trachea,  and  is  increased  unto  vomiting  by  a  deep  inspira- 
tion ;  there  is  a  constant  mucous  rattling  from  which  the 
patient  vainly  endeavors  to  obtain  relief  by  expectoration  ; 
there  is  pressing  in  the  throat,  with  a  constrictive  feeling  as 
if  he  would  be  suffocated.  The  respiration  is  exceedingly 
quick  and  laborious,  and  the  voice  is  hoarse  and  weak.  The 
skin  is  dry  and  burning,  and  the  patient  is  restless  and 
inclined  to  weep.  Dr.  Hughes  does  not  assign  Hepar  a 
prominent  place  in  the  treatment  of  croup,  merely  stating 
that  it  is  useful  in  restoring  the  laryngeal  membrane  to  its 
normal  condition  when  the  croup  is  hoarsely  mucous  ;  and 
Dr.  Duncan  considers  that  the  remedy  is  indicated  "after  the 


SPASMODIC    CROUP.  167 

spasm  is  relieved,  and  there  is  a  loose,  hoarse  cough,  worse 
towards  evening,  with  a  little  fever,  due  to  the  obstruction 
of  the  mucus."  Dr.  Edmonds  gives  this  remedy  "  for  the 
remnant  of  symptomatic  debris  that  may  be  found  on  hand 
towards  the  conclusion  of  the  case,  mainly  in  the  shape  of  a 
cough,  which  seems  rather  irritative  than  inflammatory :" 
Dissolve  a  grain  of  the  4th  or  5th  decimal  trituration  in  hajf 
a  tumblerful  of  water,  and  give  a  teaspoonful  every  half  hour 
or  oftener. 

Phosphorus  is  one  of  the  remedies  rarely  given  at  first,  but 
held  in  reserve,  as  it  were,  in  case  the  other  remedies  should 
fail.  Kreussler  says,  "  If  these  three  remedies  (Aconite, 
Spongia  and  Hepar)  should  remain  ineffectual,  or  should 
only  effect  a  partial  cure,  Phosphorus  is  still  left  us."  In 
like  manner,  Laurie  advises  Phosphorus  "  in  cases  where 
Hepar  may  fail  to  remove  the  symptoms  we  have  enumerated 
under  that  remedy  ;  or  where  Aconite  and  Spongia,  as  well  as 
Hepar  have  been  merely  productive  of  temporary  benefit." 
The  cough  of  Phosphorus  is  dry  and  tickling,  but  not  very 
harsh  sounding,  with  hoarseness  and  pain  in  the  chest  as  if 
excoriated,  and  a  continual  irritation  in  the  larynx  and 
trachea,  with  shortness  of  breath  ;  or  expectoration  of 
mucus,  with  hollow  cough.  Phosphorus  closely  resembles 
Hepar,  but  it  differs  materially  from  Spongia.  In  Phosphorus 
the  voice  is  trembling  and  hissing,  while  in  Spongia  the 
voice  is  interrupted.  The  respiration  of  Phosphorus  is 
generally  quick,  while  in  Spongia  it  is  predominantly  slow. 
In  Phosphorus  the  expectoration  is  most  constant  morning 
and  during  the  day,  while  in  Spongia  the  cough  is  generally 
dry ;  expectoration  not  constant  ;  is  loosened  in  the  morning 
and  swallowed.  Riickert  remarks  that  Phosphorus  is  some- 
times given  with  benefit  when  the  improvement  seemed  to 
stop  ;  it  did  not,  however,  accelerate  the  cure. 

Hartmann  recommends  it  for  obstinate  hoarseness  with 
slight  catarrhal  croup  remaining  after  the  disease  is  cured, 
and  he  also  gives  it  for  the  tendency  to  relapse.  Some 
twenty  years  ago   I  attended    a  case  of  croup,  and  the  child 


l68  SPASMODIC    CROl   P. 

got  well,  except  a  hoarseness  which  remained  and  excited  my 
suspicion.  But  the  parents  insisted  that  the  child  was  doing 
well.  Next  day  another  attack  of  croup  destroyed  the 
child's  life.  Since  then  I  have  never  failed  to  use  the  Phos- 
phorus under  similar  circumstances."  I  have  found  Phos- 
phorus of  great  use  for  the  weakness  remaining  after  the 
attack,  and  when  given  at  long  intervals,  and  in  the  12th  to 
the  30th  dilution,  it  often  removes  the  predisposition  to  the 
disease.  Of  late  years,  I  have  found  Sanguinaria  still  more 
effective  for  the  same  purpose.  In  acute  cases  I  use  the  5th 
or  6th  decimal  dilutions,  but  the  removal  of  the  predispo- 
sition requires  higher  potencies. 

Our  practitioners  may  thank  Dr.  Duncan,  of  Chicago,  for 
recalling  their  attention  to  Lobelia  inflata  as  a  remedy  for 
spasmodic  croup,  a  remedy  which  had  almost  passed  out  of 
our  minds,  but  which  has  done  excellent  service  in  the  past. 
"  Lobelia  cases  resemble  those  of  Aconite  with  this  differ- 
ence :  there  is  more  dyspnoea  and  the  spasm  affects  the 
oesophageal  muscles,  impeding  deglutition  as  well  as  respira- 
tion. Older  children  will  describe  a  sensation  of  a  lump  in 
the  throat  {Igu),  but  the  constant  ringing  cough,  stridulous 
breathing,  and  great  anguish  and  fear  of  suffocation,  distin- 
guish the  case  from  Ignatia  or  Aconite"  (Duncan). 

In  pressing  cases  it  would  be  well  to  consult  the  thera- 
peutics of  pseudo-membranous  croup  in  the  next  chapter, 
especially  the  remarks  on  Sanguinaria,  which  for  many  years 
has  been  my  sheet-anchor  in  both  forms  of  croup. 

The  little  patient  should  be  kept  as  tranquil  as  possible, 
and  this  is  just  as  necessary  during  the  interval  as  it  is  during 
the  attack.  The  atmosphere  of  the  sick-room  should  be 
pure  and  of  equable  temperature,  but  draughts  should  be 
carefully  avoided  ;  I  have  known  a  number  of  serious  relapses 
from  neglect  of  this  self-evident  precaution.  I  have  seen 
decided  benefit  from  charging  the  atmosphere  of  the  room 
with  the  vapor  of  warm  water.  The  dress  worn  during  the 
illness  should  be  loose  and  easy,  and  a  woollen  wrapper 
should   be   worn    in    addition   to   the   usual    night-dress.      If 


9PASM0DIC    CROUP.  L69 

possible,  the  child  should  be  kept  in  bed  during  the  entire 
time  of  the  acute  attack,  but  a  patient  would  be  safer  up 
and  dressed  than  sometimes  in  bed  and  sometimes  out  of  it 
— all  in  the  night-dress.  Condie  attaches  a  good  deal  of 
importance  to  supporting  the  child  in  an  erect  posture 
during  the  paroxysms,  and  I  have  found  that  respiration  is 
much  easier  when  this  simple  recommendation  is  followed. 

Almost  all  medical  writers  recommend  a  warm  bath,  say 
of  the  temperature  of  ioo°,  as  soon  as  possible  after  the 
commencement  of  the  attack,  with  the  view  of  relieving  the 
spasmodic  action  of  the  laryngeal  muscles.  'I  was  in  the 
habit  of  using  this  in  former  years,  but  of  late  I  have  discon- 
tinued it,  as  I  found  the  reaction  from  it  exceedingly  injurious, 
and  I  now  look  upon  the  warm  bath  as  a  decided  injury  to 
the  case.  I  have,  however,  seen  benefit  from  the  application 
of  a  sponge  soaked  in  hot  water  to  the  region  of  the  larynx 
and  trachea,  and  repeated  say  every  fifteen  or  twenty  minutes. 
Really  this  is  a  counter-irritant,  acting  by  revulsion  from  the 
larynx,  but  in  a  great  majority  of  cases  the  dyspncea,  cough 
and  hoarseness  diminish  at  once,  and  I  have  never  seen 
any  bad  result  from  it. 

The  food  should  be  light  and  easy  of  digestion,  and  should 
consist  of  bread,  rice,  arrow-root  and  the  various  preparations 
of  milk.  I  have  seen  great  good  follow  the  use  of  well-made 
beef-tea,  a  tab'lespoonful  every  two  or  three  hours. 

Condie  observes  that  "  when  the  paroxysm  is  very  violent 
and  long-continued,  and  there  is  danger  of  the  occurrence  of 
asphyxia  unless  immediate  relief  is  obtained,  the  operation 
of  tracheotomy  should  be  performed  without  delay.  But 
under  enlightened  homoeopathic  treatment,  this  must  very 
rarely  be  necessary,  save  when  the  type  of  disease  changes 
and  the  malady  becomes  pseudo-membranous  croup. 

How  can  we  prevent  spasmodic  croup?  I  have  succeeded 
in  a  great  many  cases  in  which  the  predisposition  continued 
long  after  the  completion  of  the  first  dentition  by  the 
persistent  use  of  Phosphorus,  say  twice  a  week,  on  going  to 
bed.     In  addition,  as  a  matter  of  course,  I  attended  to  the 


|-m  SPASMODIC    CROUP. 

usual  prophylactic  treatment  of  children  subject  to  this 
disease.  The  dress  should  be  warm  and  comfortable,  for  the 
custom  of  exposing  the  whole  of  the  neck  and  a  good  part 
of  the  chest,  as  well  as  the  upper  limbs  and  the  lower  ones 
from  the  knee  to  the  ankle,  is  one  of  the  worst  follies  ever 
perpetrated  in  the  sacred  name  of  Fashion.  Children  subject 
to  croup  should  wear  woollen  underclothing,  light  but  warm, 
from  head  to  foot,  and  the  night-dress  should  be  made  in 
the  same  fashion.  Dr.  Eberle  mentions,  as  showing  the 
influence  of  dress,  that  during  a  practice  of  six  years  among 
the  Germans,  who  keep  the  necks  and  chests  of  their  children 
carefully  covered,  he  met  with  but  one  case  of  this  disease  ; 
and  it  is  a  comparatively  rare  disease  in  Montreal,  where 
children  are  as  rationally  dressed  as  adults.  Exercise  in  the 
open  air  should  be  taken  whenever  the  weather  permits,  and 
the  presence  of  snow  should  not  be  a  barrier  to  a  walk  if  the 
feet  are  properly  shod.  For  many  years  I  have  followed  the 
excellent  advice  of  Dr.  J.  F.  Meigs:  "When  the  liability  to 
the  disease  continues  after  the  completion  of  the  first  denti- 
tion, I  have  found  the  daily  use  of  the  cold  bath,  in  connec- 
tion always  with  warm  clothing,  most  useful  in  preventing 
the  attacks.  The  bath  must  be  commenced  with  in  the 
Summer,  and  persevered  in  through  the  following  Winter. 
The  water,  after  the  cold  weather  begins,  should  be  drawn 
in  the  evening,  allowed  to  stand  all  night  in  a  room  in  which 
there  is  a  fire  through  the  day,  and  made  use  of  on  the 
following  day.  Prepared  in  this  way  I  have  found  the  water 
in  the  morning  at  a  temperature  of  between  500  and  6o°  F. 
The  child  ought  to  be  kept  in  the  water  only  half  a  minute 
or  a  minute,  then  well  rubbed  and  dressed  immediately." 

Aphorisms. 

1.  Spasmodic  croup  is  a  combination  of  catarrhal  laryngitis 
and  violent  spasm  of  the  interior  muscles  of  the  larynx. 

2.  Boys  are  more  frequently  affected  than  girls,  and  it  is 
most  common  during  the  first  dentition. 


PSEUDO-MEMBRANOUS   CROUP.  171 

3.  Spasmodic  croup  is  never  epidemic  in  the  proper  sense 
of  the  word,  though  it  is  sometimes  hereditary. 

4.  Spasmodic  croup  is  rarely  a  fatal  disease,  still  the 
physician  should  not  forget  the  fact  that  death  may  occur. 

5.  Danger  is  present  when  the  disease  lasts  longer  than 
forty-eight  hours,  and  the  danger  increases  with  the  prolong- 
ation of  the  attack. 

6.  The  homoeopathic  remedies  are  Aconite,  Spongia, 
Hepar,  Phosphorus,  Lobelia  and  Sanguinaria. 

7.  The  best  prophylactics  of  spasmodic  croup  are  warm 
clothing,  judicious  exercise,  regulated  bathing,  and  the 
persistent  administration  of  Sanguinaria  and  Phosphorus. 


CHAPTER  VIII. 


Pseudo-membranous  Croup 


This  is  one  of  the  most  dreaded,  and,  till  the  advent  of 
the  homoeopathic  healing  art,  one  of  the  most  fatal  of  all  the 
diseases  of  childhood  ;  and  even  with  all  the  resources  of  the 
Similia,  the  thoroughly  educated  physician  feels  some  little 
trepidation  when  he  finds  himself  face  to  face  with  a  well- 
marked  case  of  this  disease.  Here,  as  in  many  other  instances, 
immense  advantage  is  derived  from  a  thorough  knowledge  of 
the  pathology  and  pathological  anatomy  of  the  disease,  and 
when  to  this  is  joined  a  thorough  knowledge  of  our  Materia 
Medica,  the  homoeopathic  physician  is  better  armed  than 
the     practitioner    of    any    other    school     whatever.       The 


\J2  l'SKi   DO-MI  MBRAN<  >US    CROUP. 

contemptuous  ignorance  of  pathology  and  pathological 
anatomy  is  thus  keenly  reproved  by  one  of  the  most  brilliant 
writers  of  our  school :  "It  is  because  the  blind  application 
of  our  therapeutic  law  so  often  helps  us  when  we  grope 
vainly  for  the  pathology,  that  we  are  led  into  a  contempt  for 
pathology  and  such  allopathic  studies.  As  healers  we  might 
be  content  with  our  therapeutic  law  ;  but  as  physicians  we 
aver  it  is  our  duty  to  our  profession  to  develop  its  every 
branch.  To-day  we  often  do  not  know  what  we  have  cured  ; 
and  while  knowing  the  Materia  Medica  will  increase  our 
capabilities  for  curing,  it  will  not  enlighten  us  in  diagnosis 
and  pathology." 

Like  spasmodic  croup,  this  disease  has  had  a  multitude  of 
names,  many  of  which  are  mere  misnomers.  Guersant  calls 
it  "  pseudo-membranous  pharyngo-laryngitis ;:  Rilliet  and 
Barthez  style  it  pseudo-membranous  laryngitis,  in  which  they 
are  followed  by  Dr.  J.  Lewis  Smith  of  New  York;  while 
other  French  writers  persist  in  calling  it  laryngeal  diphtheria  ; 
Baehr  of  Hanover  calls  it  '  Laryngo-tracheitis  Crouposa,'  an 
uncouth  name,  but  anatomically  and  pathologically  correct. 
Fletcher  of  Edinburgh — most  homoeopathic  of  all  allopathic 
pathologists — selects  this  disease  as  a  specimen  of  the  prepos- 
terous names  with  which  nosologists  have  labelled  disease.. 
"  Croup,  which  has  successively  borne  the  names  of  suffocatio 
stridula  (Home),  catarrhus  suffocativus  (Hillary),  cynanche 
stridula  (Crawford,  Wedderburn),  angina  inflammatose  infan- 
tilis, angina  epidemica  (A.  Miller),  angina  polyposa,  angina 
suffocativa  (Baird),  asthma  infantilis  (Millar  and  Bush), 
morbus  strangulosus,  plastic  inflammation  of  the  air-passages 
(Laennec),  diphtheritis  (Bretonneau),  has  lately  been  dignified 
with  the  name  of  dento-frangibalus-broncho-laryngo-tracheitis- 
mixo-pio-meningitis,  and  this  probably  is  but  a  single 
specimen  of  what  we  must  expect  if  this  mania  be  not 
resolutely  checked."  While  some  of  these  names  are  simply 
ludicrous,  others  are  really  pernicious  nonsense  with  a  distinct 
tendency  to  mislead  the  anxious  physician.  For  example, 
Dr.  Condie,  one  of  the  best  writers  on  children's  diseases  on 


PSEUDOMEMBRANOUS    CROUP.  173 

this  continent,  heads  one  chapter  "Tracheitis-Croup  ;"  and 
two  of  the  most  recent  writers  on  the  subject — Sir  George 
Duncan  Gibb  and  Professor  Aitken — adopt  Cullen's  erro- 
neous name  of  "  cynanche  trachealis,"  and  Sir  Thomas 
Watson  styles  it  "  cymnche-trachealis-tracheitis-croup,"  and 
adds:  "The  essence  of  this  complaint  is  violent  inflamma- 
tion, affecting  the  mucous  membrane  of  that  portion  of  the 
air-passages  which  lies  between  the  laryngeal  cartilages  and 
the  primary  bronchi — in  one  word,  of  the  trachea  or  windpipe, 
This  is  the  genuine  seat  of  the  disease  ;  but  the  inflamma- 
tion  sometimes  ascends  into  the  larynx  ;  and  not  unfrequently 
it  dives  into  the  bronchi  and  into  their  ramifications."  Now, 
pseudo-membranous  croup — which  I  conceive  to  be  the  most 
appropriate  name — in  a  large  proportion  of  cases,  commences 
in  the  larynx  and  extends  downwards,  and  it  is  compatively 
seldom  that  it  commences  in  the  trachea  and  extends 
uptvards,  though  in  some  cases  a  pseudo-membranous  inflam- 
mation may  extend  from  the  bronchi  to  the  trachea. 

Pseudo-membranous  croup  is  an  inflammation  of  the 
epiglottis,  glottis  and  larynx,  frequently  extending  to  the 
trachea,  and  occasionally  reaching  to  the  larger  bronchial 
tubes,  and  this  inflammation  is  accompanied  by  the  exuda- 
tion of  a  yellowish-white  fibrinous  material  upon  the  mucous 
membrane  of  the  affected  parts ;  the  fauces  and  tonsils 
frequently  exhibit  more  or  less  of  the  inflammation  with  its 
accompanying  exudation.  The  disease,  then,  is,  in  the  words 
of  Da  Costa,  "  not  only  inflammation,  but  inflammation 
which  results  in  the  formation  of  a  false  membrane,"  and  it 
must  be  specially  noted  that  these  membranes  produce  no 
loss  of  substance,  and  that  they  leave  behind  them  no 
cicatrices.  As  a  result  of  these  morbid  changes  the  breathing 
is  difficult,  loud  and  accelerated,  with  shrill  or  wheezing 
inspiratory  murmur ;  the  voice  is  at  first  hoarse  and  rough, 
but  towards  the  close  whispering  or  extinct ;  spasm  of  the 
interior  muscles  of  the  larynx  is  almost  invariably  present, 
and  towards  the  close  of  the  disease  fragments  of  false 
membrane  are  sometimes  expectorated  or  vomitied.  Fever 
is  an  almost  invariable  concomitant. 


174  PS]  i   DO-MEMBRANOUS    CROl   P. 

M.  l.ittiv,  who  in  addition  to  his  gigantic  labors  as  a 
exicographer,  was  a  medical  writer  of  great  merit,  discusses 
the  question  whether  or  not  Hippocrates  was  acquainted 
with  croup,  but  he  does  not  give  any  decided  opinion  on  the 
matter.  The  following  passage,  however,  certainly  seems  to 
apply  to  this  disease:  "Angina  Gravissima  quidem  est,  ct 
celerrime  interimit,  quae  neque  in  faucibus  neque  in  cervice 
quicquam  conspicuum  facit,  plurimum  vero  dolorem  exhibct, 
et  difficultatem  spirandi,  qua:  erecta  cervice  obitur,  inducit. 
Hcec  enim  eodem  etiam  die,  et  secundo,  et  tertio,  et  quarto 
strangulat."  Dr.  Francis  Adams,  the  learned  commentator 
on  Hippocrates  and  Paulus  Aegineta,  considers  that  there 
can  be  no  doubt  that  the  ancients  were  well  acquainted  with 
that  species  of  cynanche  in  which  the  disease  spreads  down 
to  the  windpipe.  Few  of  us,  however,  would  agree  with  Dr. 
Adams  when  he  says,  "  It  may  reasonably  be  doubted 
whether  they  (the  ancients)  were  not  fully  as  well  acquainted 
with  diseases  of  the  fauces  and  windpipe  as  the  moderns 
are."  Baillon  (Paris,  1576)  was  the  first 'writer  of  modern 
times  to  describe  this  disease,  "  Chirurgus  affirmavit  se 
secuisse  cadaver  pueri  ista  difficili  respiratione  et  morbo  (ut 
dixi)incognito  sublati ;  inventa  est  pituita  lenta,  contumax, 
quae  instar  membrana,-  cujusdam  arteria  aspera  erat  obtenta, 
ut  non  esset  liber  exitus  et  introitus  spiritui  externo  ,  sic 
suffocatio  repentina."  According  to  Fredrich,  Baillon  was 
the  first  who  mentions  having  dissected  a  patient  who  had 
died  of  croup.  Boerhaave  and  Willis  describe  morbid  states 
strikingly  like  croup,  and  the  "  suffocative  catarrh "  of 
Ettmiiller  is  clearly  croup  under  another  name.  Dr.  Blair 
of  Cupar  Angus,  in  Scotland,  first  described  the  disease  by 
its  present  name,  in  the  year'1713.  "  The  tussis  convulsiva 
or  chink-cough,  is  also  some  years  epidemical,  and  becomes 
universal  among  children  ;  as  is  a  certain  distemper  with  us 
called  the  croops,  with  this  variety,  that  whereas  the  chink- 
cough  increases  gradually,  is  of  long  continuance,  seizes  in 
paroxysms,  and  the  patient  is  well  in  the  interval ;  this 
convulsion    of    the    larinx,  as   it   begins   so   it  continues,  so 


PSEUDO-MEMBRANOUS    CROUP.  I  75 

violently  that  unless  the  child  is  relieved  in  a  few  hours  'tis 
carried  off  within  twenty-four,  or  at  most  forty-eight  hours. 
When  they  are  seized  they  have  a  terrible  snorting  at  the 
nose  and  squeaking  in  the  throat,  without  the  least  minute 
of  free  breathing,  and  that  of  a  sudden  ;  when  perhaps  the 
child  was  but  a  little  time  before  healthful  and  well.  The 
most  immediate  cure  is  instant  bleeding  at  the  jugular, 
either  by  the  lancet  or  leeches;  when  the  most  urgent 
symptoms  are  gone,  then  emetics  or  the  like  are  adminis- 
tered at  discretion."  Two  French  writers,  Molloi  and  Malain, 
described  the  disease  in  1743  and  1745  respectively;  in  1749, 
Ghizi,  of  Cremona,  gave  a  good  account  of  it  under  the 
name  of  angina  strepitosa,  and  in  the  same  year  it  was 
described  by  Dr.  Starr,  of  Liskeard,  in  Cornwall.  In  1755, 
Dr.  Richard  Russell,  of  London,  described  the  disease  as 
observed  by  him  in  connection  with  the  epidemic  sore-throat 
then  raging,  and  he  points  out  that  "  it  is  most  apt  to  seize 
children  from  two  years  old  to  eight  or  ten,  but  chiefly  the 
younger  sort " — most  probably  laryngeal  diphtheria.  Dr. 
Francis  Home's  essay,  entitled  "An  Enquiry  into  the  Nature, 
Cause  and  Cure  of  Croup,"  appeared  in  1765,  a  carefully 
written  account  of  true  croup  as  observed  in  Edinburgh  and 
the  neighboring  towns  at  a  time  when  the  disease  was  not 
complicated  by  epidemic  affections  of  the  fauces.  Home 
regarded  the  disease  as  an  acute  inflammation  of  the  larynx 
and  trachea,  and  his  descriptions,  with  those  of  his  Swedish 
contemporaries,  Halen  and  YVahlbom,  gave  croup  a  definite 
place  among  diseases.  Millar,  who  practiced  in  Scotland  at 
a  later  date  than  Home,  published  his  "Observations  on  the 
Asthma  and  Hooping  Cough,"  in  1796,  and  he  gives  greater 
prominence  to  the  spasmodic  element  in  the  disease  than 
any  previous  writer — indeed  he  seems  to  have  spasmodic 
croup  in  his  mind's  eye  more  than  the  true  croup  of  Home. 
Some  of  these  writers,  notably  Ghizi  of  Cremona,  and 
Starr  of  Liskeard,  were  describing  what  we  would  call 
diphtheritic  croup, and  Dr.Richard  Russell  was  clearly  describ- 
ing an  epidemic  angina  which  often  extended  to  the  larynx 


\j6  PSEUDO-MEMBRANOUS    CROUP. 

and  trachea,  and  which  was  entirely  distinct  from  the 
sporadic  and  purely  inflammatory  disease  so  ably  described 
by  1  lomc.  The  latter  writer  thus  contrasts  the  two  diseases  : 
"  The  two  very  different  situations  of  the  suffocatio  stridula  ; 
the  former  more  inflammatory  and  less  dangerous  ;  the  latter 
less  inflammatory  and  highly  dangerous  ;  in  the  former  the 
pulse  is  generally  strong,  the  face  red,  drought  great,  and 
they  agree  with  evacuations  ;  in  the  latter  the  pulse  is  very 
quick  and  soft,  great  weakness,  tongue  moist,  less  drought, 
great  anxiety,  and  evacuations  hasten  death."  In  spite  of 
these  clear  diagnostic  differences,  many  epidemics  of  angina 
maligna — which  would  now  be  styled  diphtheria — in  the 
eighteenth  century  were  called  croup,  just  as  not  a  few  cases 
of  laryngeal  diphtheria  are  included  in  the  accounts  of  croup 
written  near  our  own  day. 

In  the  first  year  of  the  nineteenth  century,  Cheyne  pub- 
lished in  his  "  Essays  on  the  Diseases  of  Children,"  a  treatise 
on  cynanche  trachealis  in  which  he  maintained  the  views  of 
Home  with  great  ability,  and  many  years  later  the  same 
learned  physician  wrote  the  article  on  croup  in  the  Cyclop<cdia 
of  Practical  Medicine,  in  the  hands  of  so  many  practitioners 
on  this  continent.  From  1805  *°  ^07,  a  great  epidemic  of 
croup,  so-called,  swept  over  the  western  part  of  the  continent 
of  Europe,  and  among  its  most  illustrious  victims  was  the 
Crown-Prince  of  Holland,  nephew  of  Napoleon  the  Great 
and  brother  of  Napoleon  III.  His  uncle,  who  was  tenderly 
attached  to  the  lad,  ordered  the  institution  of  the  famous 
Concours  on  croup,  and  of  the  83  essays  sent  in,  though  many 
describe  diphtheritic  croup,  the  writers  who  carried  off  the 
principal  prizes,  J  urine  of  Geneva  and  Alhers  of  Bremen, 
unquestionably  describe  an  independent  disease,  inflamma- 
tory in  its  nature,  uncomplicated  by  malignant  angina  or  any 
epidemic  influence  whatever.  Still  later  in  point  of  time,  we 
had  a  controversy,  hardly  terminated,  between  the  observers 
who  contended  that  there  was  but  one  form  of  croup,  and 
that  other  body  of  practitioners  who  drew  a  sharp  line  of 
demarcation  between  pseudo-membranous  croup  and 
spasmodic  croup. 


PSEUDO-MEMBRANOUS    CROUP.  I  77 

In  the  last  chapter  the  writer  remarked  upon  the  fact  that 
spasmodic  croup  is  much  more  frequent  than  the  pseudo- 
membranous variety,  and  it  was  stated  that  while  spasmodic 
croup  is  a  disease  of  very  young  children,  pseudo  membran- 
ous croup  generally  affects  those  of  more  mature  years. 
Cullen  remarks,  "  This  disease  seldom  attacks  infants  till 
after  they  have  been  weaned.  After  this  period,  the  younger 
they  are,  the  more  they  are  liable  to  this  disease.  The 
frequency  of  it  becomes  less  as  children  become  more 
advanced  ;  and  there  are  no  instances  of  children  above 
twelve  years  being  affected  with  it."  The  last  assertion  is 
unquestionably  an  error,  for  it  has  been  often  seen  in  its  most 
formidable  form  in  children  at  the  breast,  and  adults  have 
died  from  it.  Bsehr  of  Hanover  questions  whether  adults 
have  ever  died  of  genuine  croup,  and  he  remarks  that  it 
occurs  even  less  frequently  before  the  second  than  after  the 
seventh  year.  This  last  remark  is  not  in  harmony  with  the 
experience  of  any  other  writer,  and  is  contradicted,  moreover, 
by  the  Vienna  statistics,  noted  for  their  accuracy.  "  Among 
501  deaths  from  croup  in  Vienna,  during  1868,  92  were  in 
the  first  year  (30  were  12  months  old,  and  12  were  1 1  months), 
128  in  the  second,  87  in  the  third,  71  in  the  fourth,  50  in  the 
fifth,  34  in  the  sixth,  17  in  the  seventh,  7  in  the  eighth,  6  in 
the  ninth,  2  in  the  tenth  and  eleventh  respectively,  3  in  the 
twelfth,  1  in  the  thirteenth,  and  1  in  the  sixty-second." 
(Glatter.)  Dr.  Condie  says  that  in  Philadelphia,  during  the 
ten  years  preceding  1845,  319  deaths  were  reported  from 
croup  in  infants  under  one  year  ;  238  in  those  between  one 
and  two  years  ;  475  in  those  between  two  and  five  years  ;  1 12 
in  those  between  five  and  ten  years  ;  and  6  in  children  over 
ten  years.  "  Of  2,136  fatal  cases  reported  in  this  city  (Phila- 
delphia) during  the  seven  years  from  1862-68,  301  were  under 
1  year  of  age  ;  571  between  1  and  2  years  ;  951  between  2 
and  5  years;  or,  1,522  between  I  and  5  years;  and  236 
between  5  and  10  years;  leaving  but  77  cases  as  occurring 
after  the  latter  period  of  life  (Meigs  and  Pepper).  The 
same  writers  add  that  of  the  35  cases  that  they  have  seen, 


i,"S  PSE Ml  MBRANi  >US    CROUP. 

28  occurred  between  2  and  7  years  of  age,  while  of  the 
remaining  7,  1  occurred  at  the  age  of  1S  months;  1  at  that 
of  19  months  ;  1  at  ~\  years  ;  2  at  1  1  years,  and  1  each  at 
11,  and  t2|  years.  In  1870,  4,302  children  died  of  this 
disease  in  England,  of  which  3,663  were  under  five  years  of 
age,  and  the  largest  number  of  deaths  was  amongst  those  in 
their  second  year.  Instances  are  reported  in  which  the  dis- 
ease occurred  at  a  very  early  age.  Morley  and  Cheyne 
speak  of  having  seen  it  in  infants  of  less  than  three  months, 
and  Bouchut  has  seen  it  in  one  only  eight  days  old.  Dr. 
Home  remarks  that  the  younger  children  are  when  weaned, 
the  more  liable  are  they,  coeteris  paribus,  to  this  malady, 
and  this  has  been  confirmed  by  Cheyne  and  other  excellent 
observers. 

In  contrast  with  whooping-cough  which  principally  affects 
female  children,  pseudo-membranous  croup  is  much  more  fre- 
quent among  males  than  females,  though  Meigs  and  Pepper 
state  that  "  sex  cannot  be  said  to  exercise  any  decided  influ- 
ence upon  the  frequency  of  this  disease,"  and  in  support  of 
this  statement,  they  point  out  that  of  the  above-mentioned 
2,136  cases,  1,115  occurred  in  males  and  1,021  in  females. 
Dr.  Squire  is  almost  of  the  same  opinion  as  the  distinguished 
Philadelphia  writers.  He  says:  "  More  boys  than  girls  are 
born  in  a  proportion  somewhat  greater  than  one  in  every 
fifty  children,  or,  to  give  the  result  of  a  very  extended  exam- 
ination, there  are  511.75  males  and  488.25  females  in  every 
1,000  births  ;  it  appears  that  of  this  number  83.71  males  and 
65.74  females  die  within  the  first  year,  after  which  the 
death  ratio  of  the  two  sexes  for  the  next  ten  years  is 
nearly  equal  ;  still  there  are  a  larger  number  of  males  than  of 
females  living  at  that  period,  and  the  deaths  of  females  from 
all  causes  are  to  those  of  males  as  87  to  100  in  the  first  five 
years,  or  as  88  to  100  in  the  first  ten  years.  Now  the  deaths 
from  croup  are  so  nearly  in  this  proportion,  and  of  late  years 
have  so  often  shown  a  difference  so  much  less  than  this,  that 
a  doubt  might  be  entertained  as- to  whether  any  difference 
in  the  liability  of  the  sexes  really  existed.      A   comparison 


PSEUDO-MEMBRANOUS    CROUP.  179 

between  the  deaths  from  all  causes  of  each  sex  for  each  year 
with  the  deaths  from  croup  at  each  year,  sex  with  sex,  shows 
a  difference  of  excess  on  the  side  of  the  males  so  constant 
that  it  is  rare  to  meet  with  an  exception,  but  at  the  same 
time  so  slight  that  it  can  only  be  considered  a  characteristic 
of  the  disease  in  the  aggregate,  corresponding  with  the 
results  of  pneumonia  and  tubercular  meningitis  rather  than 
with  the  more  characteric  zymotic  diseases,  and  contrasting 
with  those  of  diphtheria  and  whooping-cough,  where  the 
excess  of  deaths  is  greatly  on  the  side  of  the  females." 

On  the  other  side  of  the  question,  without  giving  figures, 
Felix  von  Niemeyer  states  that  "  boys  are  more  subject  to 
it  than  girls,"  and  Bashr  thinks  that  from  60  to  70  per  cent. 
of  all  cases  are  boys.  Of  429  deaths  from  this  disease  in 
Massachusetts  during  1852,  243  were  in  boys  and  178  in  girls. 
Of  Steiner's  101  cases,  yj  were  boys  and  only  24  girls  ;  of 
30  cases  reported  by  Trousseau  22  were  males  and  8  females. 
Of  Bonn's  70  cases  43  were  boys  and  2j  were  girls,  while  of 
Jauseconich's  22  cases  17  were  boys  and  5  were  girls. 
Ruehle  giving  the  proportion  of  boys  to  girls  as  3  to  2  ;  and 
the  deaths  from  croup  in  the  London  Hospitals  during  the 
year  1840  were  three  in  the  male  sex  to  one  in  the  female. 
Glatter  makes  the  curious  observation' that  among  the  Chris- 
tian population  of  Vienna  the  mortality  from  croup  is  2.6 
per  cent.,  while  among  the  Israelitish  it  is  4.2  per 
cent,  and  Steiner  confirms  this  from  his  own  experience 
in  Prague.  The  writer's  own  experience  is,  that  not  only  is 
the  disease  more  frequent  in  males  than  in  females  but  it  is, 
at  the  same  time,  more  severe  and  more  fatal,  so  that  a  little 
girl's  chances  of  life  are  much  brighter  when  attacked  with 
pseudo-membranous  croup  than  are  the  chances  of  a  little 
boy. 

Almost  all  observers  are  agreed  that  pseudo-membranous 
croup  is  largely  a  malady  of  children  of  sanguineous  temper- 
ament, plump  and  of  ruddy  complexion,  and  apparently  in 
the  enjoyment  of  excellent  health.  Drs.  Meigs  and  Pepper 
remark  of  their  35  cases  that  26  occurred  in  healthy,  vigorous 


I  So  PSEUDO  MEMBRANOUS    CROl   I  . 

children,  while  the  remaining  9  occurred  in  children  who 
though  neither  very  weak  nor  very  sickly,  presented  a  rather 
delicate  appearance.  Steiner,  in  one  article  on  croup, 
says  "  that  true  croup  appears  by  preference  in  strong 
children,  well  nourished  and  previously  healthy,  and  in 
another  paper,  of  later  date,  he  says  that  "  strong,  well-fed, 
hearty  children  are  no  more  liable  to  croup  than  those  who 
are  feeble,  delicate,  or  affected  with  other  diseases."  Felix 
von  Niemeyer  is  the  most  distinguished  writer  who  contra- 
dicts this  view,  so  generally  held  :  "  It  is  an  error  to  suppose 
that  vigorous,  full-blooded,  blooming  children  are  especially 
liable.  On  the  contrary,  tender,  delicate  ill-nourished  off- 
spring of  tuberculous  parentage,  with  pale  skin  and  conspic- 
uous veins  (an  ominous  sign  even  for  the  laity),  children 
with  a  tendency  to  moist  eruptions,  to  enlarged  lymphatics, 
or  to  acute  hydrocephalus,  suffer  from  croup  with  equal  or 
even  greater  frequence  than  those  who  are  more  robust.  It 
is  our  daily  experience  that,  in  the  great  mortality  which 
desolates  certain  families,  a  portion  of  the  members  die  of 
croup,  and  another  of  hydrocephalus,  while  in  the  survivors 
pulmonary  tuberculosis  develops  later  in  life.  It  would 
appear  that  the  croup  not  unfrequently  begins  very  soon 
after  the  disappearance  of  a  moist  eruption  on  the  head  or 
face." 

I  consider  that  scaso?i  and  temperature  exercise  a  much 
more  powerful  influence  than  constitution  and  temperament 
upon  the  development  of  true  croup,  for,  like  the  spasmodic 
croup,  it  is,  as  Cullen  remarks,  '  often  manifestly  the  result 
of  cold  applied  to  the  body,'  especially  of  sudden  transitions 
from  heat  to  cold.  Professor  Golis  of  Vienna  relates  the 
case  of  a  boy  four  years  old,  previously  in  perfect  health, 
who,  having  gone  out  from  an  over-heated  room  into  the 
open  air  during  an  extremely  cold  winter's  day,  was  seized 
while  walking  with  all  the  symptoms  of  the  most  violent 
croup,  which  proved  fatal  in  fourteen  hours.  It  is  most 
common  during  cold,  damp,  changeable  weather,  and  it  often 
attacks  children  who  live  in  overdieated  rooms  and  who  are 


PSEUDO-MEMBRANOUS    CROUP.  I  S  i 

taken  into  the  open  air  without  proper  clothing,  especially 
during  keen  east  or  north-east  winds,  or  the  prevalence  of 
sudden  changes  of  temperature.  Croup  is  four  times  as 
frequent  in  the  winter  quarter,  November,  December  and  Jan- 
uary, as  in  the  summer  quarter,  June,  July  and  August.  Dr. 
J.  Lewis  Smith  notes  that  it  is  common  among  the  poor  of 
New  York,  who  live  in  close  rooms,  over-heated  during  the 
days  and  cool  at  night,  and  Drs.  Meigs  and  Pepper  formu- 
late the  opinion  of  the  profession  by  saying :  "  The  mean 
monthly  temperature  and  the  mean  monthly  mortality  from 
croup  rise  and  fall  together  throughout  the  entire  year." 

Dr.  Cheyne  thought  that  the  liability  of  children  to  this 
disease  depended  upon  the  narrowness  of  the  chink  of  the 
glottis,  and  in  support  of  this  Drs.  Evanson  and  Maunsell 
pointed  out  that  there  is  "scarcely  any  perceptible  difference 
between  the  aperture  of  the  glottis  of  a  child  of  three  and 
one  of  twelve  years  of  age ;  while,  after  puberty,  that 
opening  is  suddenly  enlarged,  in  the  male,  in  proportion  of 
ten  to  five,  and  in  the  female,  of  seven  to  five."  Guibert 
thought  that  the  straightness  of  the  windpipe  and  particu- 
larly of  the  glottis,  "rendered  croup  more  frequent  in  infancy, 
but  is  difficult  to  see  how  it  could  have  this  effect."  Finally, 
without  going  as  far  as  Meigs  and  Pepper,  who  frankly 
admit  that  "  in  none  of  the  cases  that  we  have  seen  could 
the  exciting  cause  be  even  suspected."  I  would  remark 
that  in  very  many  cases  the  exciting  cause  is  absolutely 
inscrutable. 

Does  true  croup — pseudo-membranous  croup — ever  recur 
in  the  same  patient?  Dr.  William  Squire,  of  London,  who 
has  bestowed  extraordinary  pains  on  the  etiology  of  this 
disease,  is  confident  that  it  does  recur:  "  Children  who  have 
suffered  an  attack  are  specially  liable  to  a  recurrence  on 
exposure  to  any  of  these  causes  (exposure  to  cold,  change 
of  dress,  etc.),  and  the  recurrent  attack  is  not  always  the 
least  severe."  Yet  Dr.  Squire  is  unquestionably  describing 
true  croup — not  spasmodic  croup — which  was  certainly  in 
the  minds  of  Evanson  and  Maunsell  when  they  wrote  "  when 


t82  PSE1   I"  'Ml  MBR  \\<  M  S    CROUP. 

a  child  has  once  been  affected  with  croup,  it  must  be  consid- 
ered liable  to  a  recurrence  of  the  disease  at  any  period  until 
the  arrival  of  puberty."  Steiner  remarks  that  true  croup,  as 
a  rule,  occurs  in  the  same  child  once  only,  though  there  are 
a  few  occasional  instances  of  a  second  attack,  and  in  his  own 
experience  of  more  than  a  hundred  thousand  cases  of  disease 
among  children,  he  has  never  yet  met  with  a  single  recur- 
rence of  true  croup.  Meigs  and  Pepper  had  two  patients  in 
whom  second  attacks  occurred,  a  very  large  proportion  of  a 
total  of  35  cases.  The  writer  never  met  with  a  recurrence 
of  pseudo-membranous  croup,  and  stories  such  as  that  told 
us  by  Dewees,  who  claimed  to  have  attended  a  lady  of  forty 
for  five  attacks  of  croup  within  six  years,  are  just  so  many 
illustrations  of  the  ignorance  of  the  distinction  between  true 
croup  and  spasmodic  croup.  I  am  quite  willing,  however, 
to  admit  the  correctness  of  Baehr's  observation,  "  if  a  child 
has  been  once  attacked  with  croup,  it  retains  an  increased 
disposition  to  inflammatory  affections  of  the  larynx."  But 
these  "  inflammatory  affections  "  rarely  assume  the  form  of 
pseudo-membranous  croup. 

Steiner  speaks  of  "  a  certain  Jicrcditary  and  family  dispo- 
sition to  croupous  inflammation  in  general,  and  to  laryngeal 
croup  in  particular,"  and  in  discussing  the  subject  he  says, 
"  I  have  quite  recently  become  acquainted  with  two  unfortu- 
nate families,  in  one  of  which  all  four,  and  in  the  other  all 
three  children  died  of  membranous  croup,  within  five  years  in 
the  one  case,  and  within  four  years  in  the  other."  I  submit 
that  unless  Steiner  can  prove  that  the  parents  of  these 
children  had  had  membranous  croup  in  infancy,  it  is  clearly 
incorrect  to  speak  of  an  hereditary  disposition,  though  these 
are  probably  illustrations  of  a  family  predisposition,  which 
is  not  so  marked  in  true  croup  as  in  the  spasmodic  variety 
of  the  disease.  It  is  but  fair  to  admit  that  many  writers  of 
note  vehemently  deny  that  any  such  family  predisposition 
exists.  About  twenty-two  years  ago  I  attended  two  families 
in  whom  the  disease  appeared  in  every  child  during  the 
second    or    third    year    of  life.     The    children    were    six    in 


PSEUDO-MEMBRANOUS    CROUP.  183 

number,  of  whom   I   lost  three  ;  of  these  one  was  moribund 
when  I  first  saw  it. 

Pseudo-membranous  croup  is,  generally  speaking,  a  spora- 
dic disease,  and  though  not  so  frequently  seen  as  spasmodic 
croup,  it  is  by  no  means  such  a  rare  occurrence  as  Cullen 
supposed  it  to  be.     Many  writers  contend  that  it  is  occasion- 
ally epidemic,  and  Dr.  Churchill  gives  us  a  most  formidable 
catalogue.     "  The   principal    epidemics    of    which    we    have 
authentic  accounts  are  those    of    Paris    in    1506    (Baillon)  ; 
Cremona  in    1747  (Ghizi)  ;  Cornwall  in  1748  (Starr)  ;  Upsal, 
1762  (Rosenstein)  ;  Frankfort  in  1764  (Van  Bergen) ;  Sweden 
in    1768-72    (Wahlbom    and    Bceck) ;     Wertheim     in     1772 
(Zobel) ;     in     Galicia,     in    1778    (Hirshfeld)  ;     Clausthal    in 
1783     (Bcehmer) ;    the    United    States    in     1805     (Barker); 
Stuttgard,  in  1807  (Autenrieth)  ;  Saxony,  in  1 807-8  (Albers)  ; 
and    again,    in     181 1    (Schundtmann)  ;    at    Vienna,    1807-8 
(Golis)  ;  and  in   Maryland,  in  1807  (Chatard)."     Bouchut  is 
quite  certain    that  the  disease  is  epidemic:    "Croup  is  an 
epidemic  disease.     This  characteristic  is    a  difficult   one  to 
establish  at  Paris,  where  most  of  the'cases  are  disseminated 
and  lost  as   regards  each  medical  man  who  is  limited  to  a 
portion   of  the  field   of  public  health.     There,  there   is   no 
general    epidemic  ;     only     partial     epidemics    are    observed 
developed  in  a  quarter,  in  a  house,  or  in  a   hospital  devoted 
to    infants.     Still   more  must   these   epidemics  be  declared 
very  unfrequent,  for  only  one    has    been    observed    at    the 
hospital  for  children  at  Paris,  and  that  not  very  well  charac- 
terized.    The  epidemic  character  especially  reveals  itself  in 
limited  localities.     It  is  impossible  to  mistake  it  when  it  is 
observed    in    a    province    and  in  districts  where  nothing  is 
ignored,  and  where  the  ravages  caused  by  this  disease  in  the 
population    can    be    closely    followed."       Dr.    J.    F.    Meigs 
remarks:     "When  epidemic,  it  is  very  generally  connected 
with  angina,  while  the  sporadic  cases  frequently  begin  in  the 
larynx,  and  often  run  their  course  without  implicating  the 
pharynx.     During  the  latter  part  of  the  year  1844,  the  whole 
of   1-845,  and  a   part  of  1846,    the  disease  prevailed  exten- 


lS.|  I'SI'I   Do-Mi  Ml'.k.Wi  11  S     CR(  'I    P, 

sively  in  this  city,  and  was  in  many  cases  accompanied 
by  the  pharyngeal  affection.  During  these  years,  and 
particularly  in  1845,  measles  and  scarlatina  also  prevailed  to 
a  great  extent,  especially  the  former."  Steiner  says  that, 
"  Primary  croup  occurs  sometimes  sporadically,  sometimes, 
though  less  frequently,  as  an  epidemic;  When  several  chil- 
dren in  a  family,  or  a  large  number  in  a  neighborhood,  are 
affected  with  the  disease,  most  of  such  instances  belong 
generally  to  the  epidemic  form  ;  but  this  distinction  has  not 
been  sufficiently  observed  in  the  literature  of  croup  to  make 
it  available  for  statistical  purposes.''  "  Not  unfrequently," 
says  von  Niemeyer,  "  we  observe  its  epidemic  appearance. 
At  such  times  many  children  are  attacked,  even  in  one  small 
place,  and  often  several  children  of  the  same  family  in  quick 
succession,  and  by  the  most  intense  and  pernicious  form  of 
the  disease."  Condie  is  as  positive  on  this  point  as  his  dis- 
tinguished townsman,  J.  F.  Meigs  :  "  Of  the  frequent  prev- 
alence of  croup  as  an  epidemic,  Beige,  Canstatt,  Fleury, 
Valleix,  Wunderlich,  'and  others,  furnish  incontestable  evi- 
dence. An  epidemic  of  the  disease  is  recorded  as  having 
extended  over  the  greater  portion  of  Central  Europe  during 
the  period  between  1805  and  1807,  and  one  of  more  circum- 
scribed limits  by  Ferrand  in  'his  Thesis  on  Membranous 
Angina,  published  in  1827,  during  which,  in  a  district  of  very 
small  extent,  there  occurred  no  less  than  sixty  cases  of  croup, 
all  terminating  fatally."  The  writer  has  seen  two  epidemics 
of  pseudo-membranous  croup  of  limited  extent,  and  in  both, 
the  disease  commenced  as  an  intense  pharyngitis,  which, 
however,  was  neither  diphtheritic  nor  scarlatinous  in  its 
nature.  One  of  these  epidemics,  which  appeared  in  the  year 
1859  was  the  immediate  forerunner  of  a  very  severe  epidemic 
of  diphtheria,  of  which  but  few  cases  affected  the  larynx. 

Little  has  been  written  as  to  endemics  of  pseudo-membra- 
nous croup,  but  a  number  of  years  ago  a  series  of  facts  was 
observed  by  the  writer  which  leads  him  to  believe  that  the 
disease  may  occasionally  rage  as  an  endemic.  Briefly,  the 
facts  are   as  follows :    A  family,  the  children  of  which   had 


PSEUDO-MEMBRANOUS    CROUP.  1 8$ 

not  been  subject  to  croup,  moved  into  a  house  situated  near 
a  low  and  stagnant  creek,  and  very  soon  several  of  the 
children  had  severe  attacks  of  true  croup.  After  a  very- 
sickly  time,  that  family  removed  to  another  house  and  a 
second  family  took  their  place.  But  soon  the  second  family 
was  attacked  by  true  croup  in  a  very  severe  form,  and  they, 
too,  concluded  to  change  their  quarters.  Neither  of  these 
families  had  croup  either  before  or  after  their  resi- 
dence in  that  house,  the  subsequent  medical  history  of 
which  I  have  been  unable  to  trace.  I  have  observed  some 
other  cases  less  marked  than  the  above,  and  in  my  native 
city  of  Edinburgh  the  disease  has  been  noted  to  prevail  as 
an  endemic  in  the  Cowgate,  which  is  a  long  and  very  squalid 
street,  occupying  the  deepest  part  of  a  valley  densely 
crowded  by  buildings  of  a  very  unhealthy  nature.  Sir 
Thomas  Watson  remarks:  "Towns  situated  on  the  banks  of 
rivers  have  more  than  the  average  share  of  it ;  and  it  has 
been  observed  to  be  particularly  frequent  among  the  children 
of  washerwomen  in  such  places,  and  thus  evidently  connected 
with  exposure  to  moisture.  In  towns  so  situated,  it  has  been 
known  to  prevail  epidemically  after  an  inundation." 

Is  pseudo-membranous  croup  contagious?  This  question 
is  clearly  wrapped  up  with  the  question  of  the  identity  or 
non-identity  of  pseudo-membranous  croup  and  diphtheritic 
croup,  which  is  fully  discussed  in  the  next  chapter,  but  for 
the  sake  of  completeness,  the  question  of  contagion  will  be 
considered  here.  Aitken  avoids  the  question  altogether : 
"  While  the  annals  of  medicine  are  rich  in  descriptions  of 
epidemic  and  endemic  croup,  opinions  are  very  much  divided 
as  to  the  nature  of  the  epidemic  influence,  and  whether  or 
not  the  disease  is  contagious  or  infectious."  Bouchut  main- 
tains the  contagious  nature  of  croup,  but  his  remarks 
eviedntly  apply  to  diphtheritic  croup :  "  Its  contagious 
nature  is  far  from  being  demonstrated  ;  still  this  question 
must  not  be  answered  in  the  negative,  for  croup  often  follows 
pseudo-membranous  angina.  Now,  the  contagion  of  this 
latter  disease  has  been  demonstrated  in  the  most  positive 


t86  \'<V\   Iwk\||  \n:i:  \\,,rs    ,  i;,  ,i    |  . 

manner  by  the  observations  <>t  M.  M.  Bretonneau  and 
Trousseau.  It  is,  then,  possible  that  croup,  which  by  its 
nature  very  much  resembles  pseudo-membranous  angina, 
may,  like  it,  be  transmitted  by  contagion.  I  say  possible, 
for  in  the  present  state  of  science  a  more  positive  expression 
cannot  be  made  use  of.  It  is,  consequently,  proper  to 
separate  those  children  laboring  under  croup  from  other 
children  whose  health  has  not,  as  yet,  experienced  any 
attack."'  In  a  similar  strain  Churchill  remarks:  "Several 
authors,  Wichmann,  Bojhmer,  Field  and  others,  maintain  the 
contagiousness  of  croup  ;  but  this  is  denied  by  the  majority 
of  writers,  at  all  events  in  the  case  of  primary  croup.  Certain 
forms  of  diphtheritic  inflammation  of  the  fauces  and  pharynx 
are  undoubtedly  contagious  ;  and  as  the  inflammation  and 
exudation  sometimes  spread  to  the  larynx,  constituting 
secondary  croup,  it  may  be  so  far  regarded  as  sharing  in  the 
same  mode  of  propagation."  Steiner  says,  "  Some  authors 
regard  ordinary  inflammatory  croup  as  infectious,  but  with 
this  I  do  not  agree,  though  there  can  be  no  doubt  that  the 
diphtheritic  variety  is  eminently  contagious  ;"  and  again,  in 
a  later  paper,  "  Primary  croup  occurs  sometimes  sporadically, 
sometimes,  though'less  frequently,  as  an  epidemic.  When 
several  children  in  a  family,  or  a  large  number  in  a  neighbor- 
hood, are  affected  with  the  disease,  most  of  such  instances 
belong  generally  to  the  epidemic  form  ;  but  this  distinction 
has  not  been  sufficiently  observed  in  the  literature  of  croup 
to  make  it  available  for  statistical  purposes."  Baehr  tersely 
says  "  that  croup  is  contagious  is  only  believed  by  those  who 
regard  croup  and  diphtheria  as  identical,"  and  Condie  is 
equally  explicit :  "  Under  no  circumstances  do  we  believe 
croup  to  be  contagious."  Felix  von  Niemeyer  observes: 
"  In  some  croup-epidemics  facts  have  been  observed  which 
make  it  somewhat  probable  that  the  disease  may  spread  by 
contagion.  It  is  questionable,  however,  whether  there  may 
not  have  been  confusion  with  that  highly-contagious  malady, 
epidemic  diphtheria  ;  in  these  cases,  as  we  shall  hereafter 
demonstrate,  the   fact   that   secondary  croup    of  the   larynx 


pseudo-membranous  croup.  187 

often  accompanies  diphtheria  of  the  fauces."  Copland  says, 
"  it  has  most  indubitably  manifested  this  property  (contagion) 
when  it  has  prevailed  epidemically,  and  when  associated  with 
cynanche  maligna " — which,  in  our  day,  would  be  styled 
diphtheria.  My  old  clinical  teacher,  George  R.  Wood,  writes  : 
"The  disease  has  also  been  ascribed  by  some  writers  to 
epidemic  and  contagious  influences.  But,  if  we  except  the 
cases  which  are  apt  to  occur  during  the  prevalence  of 
epidemic  catarrh,  it  is  only  to  the  diphtheritic  disease  of 
Bretonneau  that  this  remark  is  applicable.  Original,  uncom- 
plicated croup  is  probably  never  either  epidemic  or  conta- 
gious." Pseudo-membranous  croup,  then,  may  safely  be  set 
down  as  being  non-contagious,  while  the  reverse  is  the  case 
with  diphtheritic  croup,  and,  personally,  I  agree  with  Dr. 
Squires  :  "  Croup,  indeed,  seems  to  hold  a  place  intermediate 
between  the  zymotic  class  and  those  of  the  respiratory 
organs." 

As  a  general  rule,  true  croup  is  a  primary  disease,  but 
occasionally  it  is  secondary ;  indeed,  physicians  are  only  now 
realizing  the  truth  of  Lefferts'  remark,  "  Unquestionably  in 
the  majority  of  cases  of  acute  infectious  disease  the  larynx  is 
more  or  less  implicated."  West  defines  secondary  croup  to 
be  "  that  form  which  occurs  in  the  course  of  acute,  infective 
or  general  constitutional  diseases,  pysemic  processes  and 
other  acute  or  chronic  affections."  Measles  is  said  by  all  the 
writers  who  have  touched  on  this  phase  of  the  disease  to  be 
the  malady  most  frequently  complicated  with  croup,  but 
though  I  have  attended  a  very  large  number  of  cases  of 
measles,  I  have  never  seen  the  disease  complicated  with 
croup  in  any  form.  Very  rarely  does  croup  complicate 
measles  in  the  commencement ;  more  frequently  is  it  seen  at 
the  height  of  the  eruption  ;  and  it  generally  occurs  during 
the  stage  of  desquamation.  Spasmodic  and  catarrhal  croup, 
on  the  contrary,  usually  attack  during  the  very  onset  of 
measles,  and  West  points  out  that  pneumonia,  in  all  its 
stages,  is  far  from  being  unusual,  and  is1  a  complication 
especially  to  be  feared  in  those  cases  where  croup  occurs  as 


iSS  PSEUDO-MEMBRANOUS    CROUP. 

a  secondary  affection  in  the  course  of  measles.  Scarlatina 
is  often  complicated  with  a  very  fatal  form  of  true  croup, 
and  as  the  subject  is  of  importance,  I  have  devoted  a  brief 
chapter  to  the  consideration  of  it,  to  which  the  reader  is 
referred.  Less  frequently  than  scarlatina,  small-pox  is  com- 
plicated with  croup,  and  in  a  practice  among  children 
extending  over  thirty  years,  I  have  seen  the  complication 
somewhat  frequently  in  scarlatina  and  small-pox,  but  never 
in  measles.  In  November,  1871,  I  attended  a  child,  in  whom 
vaccination  had  been  neglected,  for  confluent  small-pox. 
The  case,  though  very  severe,  did  well  till,  worn  out  with 
watching,  the  mother  did  not  notice  that  the  child  had 
slipped  from  the  bed  to  the  floor.  It  lay  there  for  three  or 
four  hours,  as  nearly  as  could  be  ascertained,  and  when 
taken  up  pseudo-membranous  croup  was  fully  developed,  and 
the  child  died  in  twenty-four  hours.  Again,  a  young  man, 
unvaccinated  and  suffering  severely  from  primary  syphilis, 
was  attacked  with  a  malignant  form  of  small-pox.  Almost 
immediately  the  larynx  was  attacked  and  the  patient  died 
in  twenty  hours.  Steiner  has  twice  noticed  pseudo-membra- 
nous croup  during  the  height  of  whooping-cough,  and  it  has 
also  been  seen  in  the  course  of  typhoid  fever. 

Croup  is  found  in  every  country  and  in  all  climates,  yet  it 
is  more  influenced  by  peculiarities  of  country  and  climate 
than  any  other  disease  of  the  respiratory  organs.  Hirsch 
points  out  that  it  diminishes  in  frequency  as  we  approach 
the  tropics,  yet  Sir  James  M'Grigor  notes  its  prevalence  at 
Bombay  in  the  year  1800 — but  as  it  attacked  adults,  it  was 
most  likely  diphtheritic  croup.  A  cold  and  moist  atmosphere, 
with  rapid  alterations  of  temperature,  and  the  vicinity  of  the 
sea,  make  up  the  climate  in  which  croup  may  almost  be  said 
to  be  endemic,  and  when  to  these  are  added  an  unknown 
yet  very  tangible  epidemic  influence,  croup  becomes  a 
veritable  scourge.  According  to  Baehr,  the  flat  country 
extending  from  Hanover  to  the  North  Sea  is  frequently 
visited  by  croup,  and  he  remarks  that  the  winds  blowing  in 
this  region  of  country  must  be  possessed  of  a  peculiar  nature 


PSEUDO-MEMBRANOUS    CROUP.  1 89 

in  order  to  cause  extensive  epidemics  which  sometimes 
snatch  away  twenty  or  more  children  in  a  single  village. 
"That  croup  is  caused  by  a  simple  cold,  is  much  more  easily 
asserted  than  proven.  The  same  child  has  many  attacks  of 
violent  laryngeal  catarrh  in  the  course  of  the  year,  but  is 
attacked  with  croup  only  during  the  prevalence  of  a  keen 
blast  from  the  north."  In  Scotland  the  greatest  mortality 
from  croup  is  not  found  in  the  extreme  north,  but  on  the 
western  and  eastern  coasts,  deeply  indented  by  the  sea, 
which  leaves  a  great  expanse  uncovered  at  every  tide,  and 
when  to  these  conditions  is  added  the  keen  easterly  winds, 
croup  rages  with  a  great  mortality,  often  exceeding  two  per 
cent,  of  all  diseases.  The  disease  is  not  nearly  so  frequent 
in  Scotland  as  it  was  when  Cheyne  first  wrote,  for  the  low, 
marshy  grounds  have  been  extensively  drained,  thus  affording 
another  illustration  of  the  pernicious  influence  of  moisture. 
The  influence  of  an  equable  temperature  is  strikingly  shown 
by  the  low  mortality  from  croup  in  the  counties  of  Wigton 
and  Dumfries  in  the  southeast  of  Scotland.  Here  the 
temperature,  though  occasionally  low,  is,  on  the  whole,  more 
equable  than  in  most  parts  of  the  kingdom,  and  the  croup 
mortality  is  always  below  one  per  cent.,  sometimes  touching 
0.5.  West  remarks  upon  the  comparative  rarity  of  croup  in 
towns,  and  its  frequency  in  rural  districts,  stating  that  "out 
of  100  children  dying  under  five  years  of  age  from  all  causes, 
more  than  four  times  as  many  will  have  died  from  croup  in 
Surrey  as  in  Liverpool,  and  exactly  four  times  as  many  as  in 
London."  Yet,  according  to  Squire,  the  highest  croup  mor- 
tality in  England  is  in  the  populous  districts  of  Lancashire 
and  Cheshire,  where,  especially  in  the  first-mentioned  county, 
the  towns  and  villages  almost  touch  each  other.  There  can 
be  no  doubt  that  in  a  dense  urban  population,  with  defective 
drainage  and  a  variable  climate,  croup  must  rage  with 
peculiar  virulence.  "According  to  the  investigations  of  later 
years,  which  indeed  are  still  incomplete,  it  appears  as  though 
the  amount  of  ozone  in  the  air  acted  an  important  part  as 
one  of  the  causative  influences  of  croup.     This  is  so  much 


190  PSE1   Im.-MI  \ir,|;  \\(  )\  g    CROUP. 

more  probable  since  the  amount  of  ozone  contained  in  the 
air  is  liable  to  the  greatest  variations  during  the  prevalence 
of  abnormal  proportions  of  electricity  such  as  are  apt  to  be 
caused  by  a  northwest  wind  "  (Baehr). 

Dr.  Elb,  of  Dresden,  questions  whether  it  would  not  be 
more  correct  to  ascribe  croup,  according  to  the  law  similia 
similibus,  to  the  presence  of  certain  component  parts  in  the 
exhalations  from  the  sea,  particularly  chlorine,  bromine  and 
and  iodine,  which  may  act  as  exciting  causes.  He  proceeds 
to  point  out  that  iodine  can  produce  croupous  symptoms, 
and  quotes  an  observation  of  Leroy's  that,  by  the  accidental 
respiration  of  chlorine,  symptoms  of  suffocation  were  pro- 
duced, and  afterwards  concretions  were  expectorated  which 
very  much  resembled  the  false  membrane  of  croup. 

The  disease  may  commence  suddenly  and  almost  without 
premonition,  but  usually  it  commences  with  uneasiness  and 
slight  shivering,  which  may  not  be  noticed  in  an  infant.  In 
children  of  robust  constitution,  whose  general  health  is  good, 
the  disease  is  apt  to  come  on  without  premonitory  symp- 
toms, but  in  children  of  average  constitution,  the  precursory 
stage  is  quite  distinctly  marked.  Again,  in  the  debilitated, 
or  in  the  scrofulous,  the  grade  of  inflammation  may  be  low, 
almost  without  fever,  and  exudation  closely  follows  on 
inflammation.  The  precursory  symptoms  are  really  those  of 
an  ordinary  catarrh,  such  as  feverishness,  sneezing,  cough 
and  hoarseness.  Baehr  says  that  "  in  very  rare,  or  rather 
exceptional,  cases,  croup  is  preceded  by  a  nasal  catarrh, 
which,  when  present,  is  a  tolerably  certain  guarantee  against 
the  possible  occurrence  of  croup."  The  rough  cough  and 
the  hoarseness  are  symptoms  that  should  excite  attention, 
for  in  a  young  child  they  are  never  wholly  devoid  of  danger, 
and  I  am  satisfied  that  many  lives  have  been  lost  from  want 
of  attention  to  this  indication.  Drs.  Evanson  and  Maunsell 
urge  us  to  look  with  suspicion  upon  these  two  symptoms — 
hoarseness  and  rough  cough — for  we  can  never  be  too  early  in 
our  recognition  of  croup.  Note  that  this  cough  differs  from 
the  cough  of  spasmodic  croup  in  being  less  hoarse  and  more 


PSEUDO-MEMBRANOUS    CROUP.  191 

sonorous.  The  eyes  are  suffused  and  the  child  is  drowsy,  and 
I  am  inclined  to  believe  that  the  latter  symptom  is  much 
more  marked  than  it  is  in  an  ordinary  catarrh.  The  respira- 
tion is  not  irregular  except  after  exertion,  and  there  is  slight 
pain  on  swallowing,  with  vague  uneasiness  in  the  larynx;  but 
these  symptoms  are  almost  wholly  unnoticed  in  infants,  and 
are  likely  to  be  overlooked  even  in  older  children.  The 
little  patient  is  chilly  at  times  and  the  chilliness  is  succeeded 
by  heat  of  the  skin,  with  lassitude  and  loss  of  appetite. 
The  pulse  is  frequent  and  a  little  harder  than  usual,  and 
the  countenance  is  slightly  flushed.  This  is,  of  course,  a 
catarrhal  fever,  but  not  every  catarrhal  fever  develops  into 
croup,  even  when  the  laryngeal  complication  is  quite  marked  ; 
for,  in  the  words  of  Dewees,  "  it  would  appear  that  it  is  not 
sufficient  for  the  production  of  croup  that  the  mucous 
membrane  of  the  windpipe  be  merely  inflamed  ;  but  that  it 
requires  a  modification  of  inflammation  to  induce  it."  The 
two  indications,  then,  which  should  suggest  croup  to  the 
mother  are  roughness  of  the  voice  and  hoarse  cough.  If  at 
this  stage  the  throat  be  examined — and  an  examination 
should  never  be  neglected — it  will  be  found  that,  even  in 
cases  in  which  the  child  has  not  complained  of  difficulty  in 
swallowing,  there  is  more  or  less  congestion  of  the  fauces, 
with  exudation  of  small,  pearly,  fibrinous  spots  on  the  soft 
palate,  uvula,  tonsils  and  posterior  wall  of  the  pharynx. 
These  spots  are  at  first  mere  islands,  but  they  soon  spread, 
and  when  found  in  conjunction  with  the  rough  and  husky 
voice  and  the  hoarse  cough,  a  morbid  state  is  revealed  which 
should  awaken  the  gravest  apprehensions.  This  entire 
morbid  state,  of  course,  as  Dr.  Squires  points  out,  follows 
quickly  upon  the  cause  which  excited  it,  and  it  may  last  for 
three  or  four  days,  though  it  very  seldom  precedes  the  out- 
break of  the  disease  more  than  twenty-four  or  thirty-six 
hours.  Even  from  the  very  commencement  all  the  symp- 
toms are  aggravated  at  night,  and  nocturnal  exacerbations 
are  the  rule  throughout  the  disease.  As  Dr.  Charles  West 
accurately  remarks,  "thirty-six  hours  seldom  pass^  without 


\()2  rSKUDO  MEMI5RANOUS     CROUP. 

the  supervention  of  some  symptom  which,  to  the  well- 
schooled  observer,  would  betray  the  nature  of  the  coming 
danger."  But  the  precursory  stage  may  be  absent,  and  in 
the  robust  or  in  the  scrofulous  the  laryngeal  inflammation 
followed,  or  rather  accompanied,  by  exudation,  may  be  the 
first  intimation  of  danger.  Professor  Wood  says:  "I  once 
attended  the  case  of  a  little  girl  who,  when  first  visited,  was 
running  about  the  apartment  with  no  other  apparent  disease 
than  a  whispering  voice,  and  perhaps  some  little  difficulty  of 
respiration  ;  yet  she  was  at  that  moment  almost  as  surely 
condemned  to  death  as  though  she  had  been  already  in  the 
last  stage  of  the  disease  ;  for  the  membrane  was  already 
formed,  and  no  efforts  could  prevent  its  fatal  progress."  The 
writer  has  attended  a  number  of  cases  in  which,  aft6r  some 
over-exertion  at  play,  or  after  exposure  to  cold,  children 
were  attacked  without  warning ;  but  this  sudden  onset  is  of 
rare  occurrence.  Sometimes  pseudo-membranous  croup  is 
developed  in  the  course  of  spasmodic  croup — especially  if 
the  child  has  had  repeated  attacks — and  the  possibility  of 
this  should  be  kept  in  view  by  the  mother  and  by  the 
physician. 

The  outbreak  of  the  fully  developed  disease  almost  always 
takes  place  about  midnight.  The  early  part  of  the  night 
may  be  passed  in  quiet  sleep,  but  the  child  is  suddenly 
aroused  by  a  severe  paroxysm  of  cough,  or,  more  rarely,  by 
a  series  of  coughs,  gradually  increasing  in  number  and 
violence.  This  second  stage  is  marked  by  a  change  in  the 
character  of  the  cough,  which  has  a  ringing,  brassy  clangor, 
which  can  never  be  forgotten  when  once  heard.  Evanson 
and  Maunsell  say  that  the  cough  is  sharp  and  ringing,  as  if 
passed  through  a  brazen  trumpet,  and  Badir  compares  it  to 
the  bark  of  a  watch-dog,  but  all  comparisons  poorly  picture 
its  ominous,  ringing  resonance.  This  change  in  the  character 
of  the  cough  heralds  a  change  in  the  respiration,  which 
becomes  prolonged  and  stridulous — a  loud  rattling  noise 
succeeding  each  inspiration  as  well  as  each  paroxysm  of 
cough.     In  the  most  severe  cases  this  loud,    rattling  noise 


PSEUDO-MEMBRANOUS    CROUP.  IQ3 

accompanies  the  expiration  as  well  as  the  inspiration.  The 
inspirations  are  audible,  wheezing  and  much  longer  than 
normal, and  the  respiratory  acts  are  greatly  more  frequent  than 
in  health,  from  28  to  36  to  the  minute,  occasionally  as  high 
as  48.  The  paroxysms  of  dyspnoea  are  of  the  most  frightful 
character.  The  child  sits  up  in  bed,  stretches  his  head  back- 
wards, and  instinctively  does  all  he  can  to  force  air  through 
the  narrowed  glottis.  The  hoarseness,  which  was  present 
during  the  first  stage,  is  now  replaced  by  an  almost  complete 
suppression  of  voice,  which  falls  to  an  almost  inaudible  whis- 
per. The  cough  loses  its  ringing,  sonorous  sound  and 
becomes  dry,  husky,  and  apparently  confined  to  the  throat. 
It  is  distinctly  paroxysmal,  and  though  it  is  sometimes 
frequent,  in  other  cases  it  occurs  at  long  intervals,  and  I  have 
noted  that  the  frequent  cough  is  a  more  favorable  sign  than 
the  rare  cough,  while  the  complete  or  almost  complete 
suppression  of  cough  is  a  very  bad  sign  indeed.  As  the  second 
stage  progresses,  the  cough  becomes  shorter  and  more ' 
smothered,  till  as  Dr.  Meigs  remarked,  "  it  might  very  well 
be  called  whispering."  The  breathing  now  becomes  still 
more  difficult,  the  cough  assumes  the  muffled  and  husky 
character,  the  gestures  of  the  child  indicate  pain  in  the 
throat  or  upper  part  of  the  sternum,  the  face  becomes  swollen 
and  darkened,  the  anxiety  and  unrest  becomes  excessive, 
and  all  the  symptoms  indicate  approaching  suffocation.  The 
little  one  starts  up  in  bed  and  begs  piteously  to  be  taken  in 
his  mother's  arms,  immediately  he  entreats  to  be  put  back  to 
bed  again  ;  he  grasps  his  windpipe  as  if  he  would  tear  out 
the  obstruction  to  respiration  ;  he  tosses  about  in  his  crib, 
catching  at  its  sides  in  his  agony  ;  the  face  is  livid  and  dis- 
torted ;  the  red  and  swollen  eyes  almost  start  from  their 
sockets  ;  the  veins  in  the  head  and  neck  are  thick  and  blue 
and  cord-like  ;  cold  perspiration  covers  the  brow,  yet  the 
cough,  in  spite  of  the  most  desperate  exertions,  is  still 
soundless,  accompanied  by  the  expectoration  of  a  very  little 
tenacious  mucus,  mingled  with  froth.  "  In  a  word,"  says 
Steiner,  "  we  have  before  us  the  heartrending  picture  of  a 


|().|  PSEUDO-MEMBRANOUS    CROl  P. 

child  nearly  suffocated,  tortured  with  the  death-pang;  a 
picture  which  draws  out  all  our  compassion,  and  brings  home 
to  us,  as  few  other  diseases  do,  the  painful  side  of  our 
calling." 

In  the  early  part  of  the  attack  there  is  no  expectoration, 
or  perhaps  a  little  viscid  mucus  ;  but  during  the  second  stage 
there  may  be  expectoration  of  false  membrane  in  small 
pieces,  mixed  with  ordinary  mucus.  Dr.  Meigs  says  that  to 
"  detect  the  membrane,  the  substance  expectorated  or 
vomited  ought  to  be  placed  in  water,  when  the  former  detaches 
itself  from  the  mucus  and  other  matters  and  is  easily  recog- 
nized." When  first  thrown  out  on  the  mucous  membrane  of 
the  pharynx  and  larynx  the  yellowish  exudation  is  quite  fluid, 
but  it  soon  coagulates,  and  when  discharged  it  is  in  shreds  of 
various  sizes  and  thickness,  or  complete  casts  of  the  larynx 
may  be  ejected  with  immediate  relief  of  the  symptoms. 
Quite  often  I  have  seen  membranes  of  the  consistence  of  the 
upper  layer  of  thick  cream,  and  I  have  noted  membranes  as 
dense  and  firm  as  kid  leather  ;  sometimes  the  creamy  mem- 
brane comes  away  mingled  with  shreds  of  the  denser  type. 
Valleix  detected  the  membrane  in  26  cases  of  51,  and  Drs. 
Meigs  and  Pepper  write,  "  Of  the  35  cases  observed  by  our- 
selves, it  was  expelled  by  vomiting  or  coughing  in  12  ;  in  21 
none  was  ejected,  though  its  presence  in  each  case  was 
proved  by  the  character  of  the  symptoms  and  by  its  exist- 
ence in  the  fauces,  by  autopsy  or  by  the  operation  of 
tracheotomy  ;  in  one  there  was  expectoration  of  masses  of 
viscid,  yellowish  fibrin,  though  none  of  membrane  ;  and  in 
tone  there  was  no  positive  evidence  of  its  existence."  At 
times  a  fragment  of  false  membrane  is  detached,  wholly  or 
in  part,  from  the  laryngeal  mucous  membrane,  and  is  carried 
below  the  vocal  cords,  causing  a  long-drawn,  suffocative 
paroxysm,  which  may  prove  fatal  unless,  by  a  desperate 
effort,  the  membrane  is  dislodged.  When  the  loosened 
membrane  is  of  small  size  it  makes  a  flapping  noise,  easily 
recognized  by  the  stethoscope. 

It  will  be  noticed  that  all  the   symptoms    remit,  but  are 


PSEUDO-MEMBRANOUS    CROUP.  195 

never  wholly  absent,  and  the  slightest  cause,  as  taking  a  little 
food  or  saying  a  few  words,  causes  an  immediate  return,  with 
increased  violence.  At  first  the  fever  is  slight,  and  in  many 
cases  it  is  altogether  absent,  but  in  the  second  stage  fever  is 
almost  invariably  present,  and  in  general  terms  it  may  be 
said  to  be  high  in  proportion  to  the  extent  and  intensity  of 
the  local  inflammation.  The  pulse,  which  was  full  and  hard 
during  the  first  stage,  and  from  1 10  to  125  to  the  minute, 
in  the  second  stage  is  slightly  more  frequent,  rising  20  to  30 
beats  during  the  suffocative  paroxysms  and  falling  as  much 
during  the  remissions.  If  the  disease  should  extend  to  the 
bronchial  tubes,  at  once  the  pulse  increases  in  frequency. 
While  the  disease  is,  as  a  rule,  marked  by  remissions  in  some 
cases,  in  the  words  of  Professor  Wood,  it  "  marches  directly 
onward  to  suffocation  almost  without  paroxysms."  The 
suffocative  attacks  seem  an  age  to  the  anxious  medical 
attendant  and  still  more  anxious  mother  ;  in  reality  they  last 
but  three  to  six  minutes,  rarely  a  quarter  of  an  hour,  and 
they  commonly  end  in  a  certain  relief,  marked  by  a  brief 
slumber,  but  the  wheezing  inspirations  tell  of  the  continued 
presence  of  a  terrible  danger.  As  morning  approaches  there 
is  a  longer  remission  of  all  the  symptoms,  even  of  the  loud 
rattle,  and  a  sleep  of  some  length  is  obtained  ;  but  I  am  not 
prepared  to  say  with  Baehr,  "  in  the  morning  the  little 
patient  may  feel  quite  well,  except  perhaps  a  little  weak  and 
languid."  That  is  not  my  experience,  for  next  day  I  always 
have  very  sick  patients  on  hand,  in  whom  a  mere  remission 
of  the  disease  is  present,  thus  affording  precious  time  for 
further  treatment.  I  grant  that  croup,  as  a  general  rule, 
shows  a  decided  remission  in  the  morning,  which  sometimes 
almost  amounts  to  an  intermission  ;  certainly  the  respiration 
is  more  free  and  the  voice  returns,  and  the  fever,  too,  abates, 
and  even  the  cough  is  less  frequent.  But  the  cough  has  a 
reedy,  piping  tone  which  suggests  trouble  during  the  coming 
night,  the  fever  shows  that  the  local  inflammation  still 
exists,  and  on  examining  the  pharynx  it  will  be  found  that  in 
a  majority  of  cases  pearly  islands  of  false  membrane  tell  of 


196  PSEUDO-MEMBRANOUS    CROUP. 

still  greater  deposits  in  the  larynx.  Note  that  this  remission 
is  the  time  for  successful  treatment.  Neither  do  I  agree  with 
my  distinguished  German  colleague  when  he  writes:  "Up 
to  this  period  (the  morning  after  the  night  "in  which  the  fully 
developed  disease  appeared),  croup  resembles  an  ordinary 
attack  of  laryngitis  so  perfectly  that  it  is  often  impossible  to 
distinguish  one  from  the  other.  This  uncertainty  and 
vagueness  of  the  symptoms  may  continue  during  the  second 
and  even  third  night,  although  the  croupy  character  of  the 
attack  becomes  more  and  more  marked  as  the  disease  pro- 
gresses on  its  course."  So  far  as  my  experience  goes,  the 
characteristics  of  this  truly  frightful  disease  are  present  from 
the  time  of  its  first  outbreak.  Only  in  comparatively  rare 
cases  can  there  be  any  doubt  as.  to  the  diagnosis  on  the 
morning  after  the  attack.  One  little-noted  characteristic 
of  the  disease  is  apt  to  throw  the  practitioner  off  his  guard, 
that  is,  that  the  first  paroxysm  is  often  followed  by  a 
remission  so  nearly  perfect  that  the  most  careful  ausculta- 
tion is  needed  to  prove  the  existence  of  the  disease. 

Let  us  pause  here  and  consider  the  mechanism  of  the 
disease,  for  much  depends  on  a  knowledge  of  it.  The 
dyspnoea  of  croup  has,  from  the  first,  fixed  the  attention  of 
medical  observers,  and  the  old  view,  once  universally  held, 
is  that  it  is  mechanically  produced  by  the  croupous  mem- 
branes. Later,  the  idea  of  spasm  of  the  glottis  gained  a 
number  of  adherents,  and  Billard  and  other  French  writers 
still  maintain  this  hypothesis.  Another  explanation  given 
by  Bretonneau,  and  still  held  by  a  small  number  of  practi- 
tioners, is  that  the  dyspnoea  is  caused  by  the  difficulty  with 
which  the  secretions  of  the  bronchi  are  forced  through 
the  glottis  narrowed  by  the  deposit  of  false  membranes. 
Rokitansky  maintains  that  "the  infiltrated,  pale,  relaxed 
muscular  tissue,  in  croupous  inflammation,  is  stricken  with 
palsy,"  and  he  looks  upon  dyspnoea  as  a  result  of  the 
paralysis  of  the  laryngeal  muscles.  These  views  of  Roki- 
tansky are  supported  by  Schlautmann  and  von  Niemeyer, 
and  the  latter  points  out  that  section  of  the  par-vagum  nerve 


PSEUDO-MEMRRANOUS    CROUP.  197 

in  young  animals  furnishes  absolute  proof  that  paralysis  of 
the  muscles  of  the  larynx  produces  dyspnoea ;  nay,  the 
dyspnoea  arising  in  consequence  of  this  experiment  bears  so 
strong  a  resemblance  to  croupous  dyspnoea,  is  attended  by 
such  similar  long-drawn,  whistling  inspiratory  efforts,  and 
other  signs,  that  the  similarity  of  the  two  conditions  must 
strike  the  most  indifferent  beholder."  Dr.  von  Niemeyer 
further  remarks  that  in  paralysis  of  the  laryngeal  muscles 
the  inspiration  is  laborious  and  prolonged,  while  the  expira- 
tion is  free  and  almost  normal,  and  he  sums  up  his  views  on 
this  interesting  topic  by  stating  that  paralysis  of  the  laryngeal 
muscles  causes  laborious  and  whistling  inspirations  with  free 
expiration,  while  the  narrowing  of  the  glottis  by  croupous 
membrane  is  really  an  interference  with  both  entrance  and 
exit  of  air,  hence  the  difficulty  in  both  inspiration  and 
expiration.  There  is  truth  in  all  these  apparently  discordant 
views,  but  their  supporters  have  been  too  one-sided,  for  any 
intelligent  physician  who  carefully  studies  a  few  cases  of  this 
disease  will  see  that  the  dyspnoea  has  three  distinct  sources 
— mechanical,  spasmodic  and  paralytic — and  of  these  the 
most  influential  is  certainly  the  mechanical  one — the 
narrowing  of  the  larynx  by  the  swelling  of  its  walls  and  the 
false  membrane  deposited  on  its  surfaces.  Paralysis  of  the 
laryngeal  muscles  is  present  in  many  cases,  and  certainly 
spasm  of  the  glottis  is  common,  and  these  three  factors  make 
up  the  dyspnoea  of  pseudo-membranous  croup. 

The  vocal  cords  swell  and  thicken,  and  they  are  coated 
with  a  very  delicate  false  membrane,  which  gradually 
increases  in  thickness,  and,  as  a  result  of  these  morbid 
changes,  the  vibratility  of  the  cords  is  altered.  Hence  the 
characteristic  hoarseness.  The  older  practitioners  considered 
that  the  cough  was  caused  by  spasm  of  the  glottis,  but  it  is 
now  known  that  the  tone  of  the  cough,  like  the  changes  in 
the  voice,  depends  on  the  same  swelling  and  thickening  of 
the  vocal  cords,  resulting  from  the  deposit  upon  them  of  the 
characteristic  false  membrane.  As  a  result,  the  cords  are 
greatly  less  mobile  than  in  health,  and  hence  the  voice  is, 


loS  PSEUDO-MEMBRANOUS    CROUT. 

from  the  fust,  rough  and  harsh,  then  crowing  and  barking, 
and  finally,  it  is  suppressed.  Quite  likely,  a  partial  paralysis 
of  the  muscles  which  open  the  glottis— the  crico-arytaenoidei 
postici — is  an  essential  ingredient  in  the  changes  in  the  voice 
and  in  the  tone  of  the  cough. 

As  a  rule,  then,  the  patient  on  the  morning  after  the  first 
nocturnal  attack  has  some  degree  of  hoarseness  of  the  voice, 
with  a  hoarse  and  resonant  cough,  and  I  have  noted  that  a 
free  and  frequent  cough  gives  better  promise  of  recovery 
than  an  infrequent  or  suppressed  one.  The  pulse  will  be 
fuller  and  more  frequent  than  natural,  and  the  temperature 
will  be  a  degree  and  a  half,  or  so,  higher  than  the  normal. 
As  night  approaches  the  breathing  becomes  loud,  difficult 
and  wheezing,  the  cough  is  of  the  same  character  as  on  the 
previous  night,  only  less  sonorous  and  more  distressing,  and 
already  the  patient  feels  the  sensation  of  impending  suffo- 
cation. When  the  paroxysm  of  cough  approaches  the  little 
patient  rises  in  his  bed,  clutches  at  the  mother  with  a 
dreadful  energy,  or  falls  down  as  if  convulsed.  But  little 
expectoration  attends  the  cough,  at  best  a  small  amount  of 
glairy  mucus,  sometimes  blood-streaked,  is  discharged.  The 
pulse  is  hard  and  frequent,  though  the  temperature  is  some- 
what lower  than  on  the  previous  night.  The  face  is  flushed 
and  swollen,  and  the  voice,  hoarse  at  the  beginning  of  the 
night,  is  often  almost  inaudible  by  morning.  At  the  very 
latest  the  disease  is  at  its  height  by  the  close  of  the  third 
day,  but  often  long  before  that  time  the  intensity  of  the 
attack  has  developed  the  third  stage — the  stage  of  asphyxia, 
or  rather  of  threatening  suffocation.  As  this  stage 
approaches,  the  remissions  between  the  paroxysms  grow 
shorter  and  shorter,  till  the  paroxysm  is  continuous  or 
nearly  so.  The  voice  is  whispering  or  entirely  suppressed  ; 
the  cough  is  dry,  stilled,  infrequent  or  entirely  absent;  the 
respiration  is  slower  and  more  convulsive  from  the  mechanical 
obstacle  to  the  entrance  of  air;  and  both  inspiration  and 
expiration  are  marked  by  a  loud  stertorous  noise.  The  child 
is  drowsy,  and  from  that  ominous  slumber  it  starts  in  terror 


PSEUDO-MEMBRANOUS    CROUr.  1 99 

and  grasps  at  the  poor  throat.  The  cool  skin  is  now  covered 
by  clammy  sweat ;  the  pulse  is  too  rapid  and  too  weak  to 
be  counted  ;  the  respiration  is  so  superficial  that  the  dyspncea 
is  scarcely  noticeable,  and  the  loud  stridor  is  no  longer 
present ;  at  each  inspiration  the  larynx  is  drawn  downwards 
towards  the  sternum  ;  at  times  a  desperate  rally  is  made  and 
the  child  struggles  hard  for  breath,  but  the  face  becomes 
cyanotic,  the  extremities  cold,  and  death  takes  place  amid 
coma  or  convulsions,  which  sometimes  strikingly  resemble 
those  of  spasm  of  the  glottis.  The  closing  symptoms  are 
caused  by  the  overloading  of  the  blood  with  carbonic  acid, 
as  much  as  3.27  per  cent,  has  been  found  in  the  expired  air. 
When  a  favorable  change  takes  place  it  is  usually  before 
the  appearance  of  the  third  stage,  for  a  very  small  number  of 
these  recover.  Usually  a  discharge  of  false  membrane  is 
one  of  the  first  signs  of  amendment,  and  this  discharge  is 
sometimes  preceded  by  a  sound  in  the  larynx  as  of  loosened 
membrane  flapping  to  and  fro  with  the  respiratory  movements. 
Generally  the  expectorated  matter  is  simply  tough,  and 
whitish  shreds  mingled  with  muco-pus — only  rarely  is  a 
cylindrical  cast  of  the  affected  parts  ejected.  Bsehr  remarks 
that  when  a  cylindrical  cast  is  thrown  off,  it  is  not  safe  to 
regard  the  danger  as  entirely  over  until  at  least  two  days 
have  elapsed  without  any  trace  of  a  renewed  exudation 
having  been  perceived.  The  cough  becomes  milder,  the 
breathing  easier,  the  larynx  clearer,  the  fever  ceases,  the  skin 
becomes  moist  and  soft,  and  slowly  but  surely  the  child 
enters  upon  convalescence.  The  amendment  may  be  sudden 
or  gradual,  and  the  writer  has  observed  that  a  sudden 
amendment  is  more  likely  to  be  followed  by  a  relapse  than  a 
gradual  one.  Dr.  West  thus  describes  a  striking  phase  of 
the  malady  :  "  The  mitigation  of  the  disease  may  be  accom- 
panied by  great  drowsiness,  which,  however,  does  not  excite 
alarm,  since  it  is  very  naturally  attributed  to  the  exhaustion 
produced  partly  by  the  disease,  partly  by  the  remedies. 
During  sleep  the  respiration  is  deep  and  tranquil,  like  that  of 
a  person  in  a  sound  slumber  ;  it  is,  indeed,  attended  by  a 


200  PSEUDO-MEMBRANOUS    CROUP. 

kind  of  wheeze,  but  presents  little  of  the  croupy  stridor ;  and 
when  awake  the  child  is  quite  sensible,  and  even  cheerful. 
Altera  time,  however,  it  becomes  difficult  thoroughly  to  rouse 
him  ;  his  pulse  grows  more  rapid  ;  the  moisture  on  his  skin 
changes  almost  imperceptibly  to  a  cold,  clammy  sweat,  and 
convulsive  twitchings  of  the  angles  of  the  mouth  occasionally 
disturb  the  repose  of  the  features.  Silently,  but  surely,  the 
exudation  has  been  making  progress,  and  when  the  alarm  is 
taken  it  is  too  late  ;  the  stupor  deepens  and  the  child  dies 
comatose,  or  rouses,  only  to  spend  its  last  hours  in  the  vain 
struggle  for  breath,  and  embittered  by  all  the  painful 
circumstances  which  ordinarily  attend  the  suffocative  stage 
of  croup." 

At  times,  the  course  of  this  disease  is  extremely  rapid. 
Much  depends  on  the  vitality  of  the  child  and  a  good 
deal  upon  its  docility.  In  cases  where  the  remissions  are 
completely  absent,  the  disease  marches  on  to  a  fatal  termi- 
nation in  from  twenty  to  thirty-six  hours.  I  attended  one 
fine  boy,  seen  after  an  illness  of  only  eight  hours,  who  died 
at  the  close  of  the  eighteenth  hour;  Vogel  says  that  the 
shortest  time  he  has  known,  from  the  invasion  of  the  malady 
till  death,  was  twenty-four  hours,  and  Dewees  has  seen  it 
run  its  course  in  a  few  hours.  Generally,  the  disease  lasts 
from  three  to  five  days,  and  Dr.  Copland  has  noted  that  a 
fatal  issue  is  most  common  on  the  fourth  day.  Dr.  Craigie 
says  that  it  is  never  protracted  beyond  the  eleventh  day, 
but  Steiner  has  seen  in  a  child,  five  years  of  age,  false 
membranes  upon  the  bronchial  mucous  membrane  even 
forty-nine  days  after  tracheotomy,  and  he  is  certain  that 
exceptionally  the  disease  may  run  three,  four  or  more  weeks. 
He  adds,  "the  longest  duration  is  in  the  ascending  croup." 
Drs.  Meigs  and  Pepper's  cases  lasted  from  three  to  fourteen 
days,  and  Vogel's  longest  case  died  after  eight  days  illness. 

No  very  large  number  of  thermometric  observations  have 
been  made,  and  they  all  confirm  the  remark  of  Wunderlich, 
that  in  no  other  diseases  has  the  temperature  so  little  signifi- 
cance   as    it    has    in    croupous    and    diphtheritic    affections. 


PSEUDO-MEMBRANOUS    CROUP.  201 

During  the  incipient  stage  of  the  disease,  the  thermometer 
shows  a  temperature  varying  from  990  to  ioo° ;  on  the  night 
of  the  outbreak  it  may  be  1020,  rising  to  1030  or  so  during 
the  paroxysms  of  dyspncea,  and  falling  with  their  departure. 
During  the  next  day  the  temperature  is  ioo°  to  ioi° — the 
higher  the  temperature  the  more  severe  the  attack  during 
the  approaching  night.  But  during  that  second  night  the 
temperature  rarely  equals  that  of  the  first,  and  it  continues 
to  decline  unless  bronchial  or  pulmonary  complications 
appear,  when  it  may  rise  to  1040,  105°,  or  even  1060  in 
exceptional  cases.  I  have  attended  a  number  of  cases  in 
which  the  temperature  never  rose  above  1010,  and  then  I 
had  reason  to  .remember  the  warning  of  Wunderlich, 
"  moderate  or  even  normal  temperatures  do  not  give  the 
slightest  guarantee  for  a  favorable  termination."  Dr.  Squire 
remarks  that  "a  high  temperature  at  the  very  outset  may 
point  to  one  of  the  exanthemata,  its  persistence  to  diph- 
theria." 

The  larynx  is  the  seat  of  pseudo-membranous  croup,  but 
the  larynx  is  very  rarely  the  only  organ  affected,  the  inflam- 
matory irritation  usually  passing  down  the  trachea  and  bron- 
chial tubes,  even  extending  to  the  bronchioles.  The  older 
writers  divide  croup  into  "descending"  and  "ascending," 
but  for  many  years  there  has  been  a  strong  disposition  to 
question  the  existence  of  the  ascending  croup,  and  many 
physicians  in  large  practice  among  children  have  never  seen 
a  case.  Steiner,  however,  has  attended  four  well-marked 
cases  of  ascending  croup.  "  In  each  case  the  disease  began 
with  slight  febrile  symptoms,  more  or  less  cough  of  a  painful 
character,  and  dyspncea.  After  from  four  to  six  days,  while 
the  voice  was  still  completely  sonorous  and  without  any 
indication  whatever  of  laryngeal  obstruction,  croupous  mem- 
branes were  expectorated.  Towards  the  end  of  the  first 
week,  and  in  two  of  the  cases  on  the  fourteenth  day — the 
fever  still  continuing — hoarseness  occurred,  followed  by 
laryngeal  stenosis  in  its  full  intensity,  and,  shortly  before 
death,   by  the   deposit  of  false   membrane  upon   the  faucial 


PSEUDI  >-MEMBF  \\<  >US    CROUP. 

mucous  membrane.  In  each  case  the  disease  was  ascribed 
to  a  severe  chill  ;  three  died,  and  one,  a  girl  live  years  of 
age,  recovered."  He  adds,  "  rare  as  such  cases  certainly  are, 
their  occurrence  is  unquestionable." 

Trousseau  says  that  "the  admirable  diagnostic  methods — 
auscultation  and  percussion  given  by  Laennec  to  the  pro- 
fession for  the  general  good,  ami  of  which  no  one  is  allowed 
to  be  ignorant,  are  in  our  hands  what  the  telescope  and 
magnifying-glass  are  in  the  hands  of  the  astronomers  and  the 
naturalist,  instruments  intermediary  between  external  objects 
and  the  mind,"  and  it  is  precisely  in  the  laryngeal  diseases  of 
children  that  the  stethoscope  is  too  much  neglected.  I  have 
found  Cammann's  stethoscope,  especially  the  single  one, 
immeasurably  superior  to  the. old  instrument,  stigmatized  by 
Abernethy  as  being  "a  piece  of  wood  with  a  patient  at  one 
end  and  a  fool  at  the  other."  Especially  in  croup  has  it 
served  a  good  turn,  though  it  is  not  an  infallible  means  of 
diagnosis,  for  Dr.  West  says  that  he  noticed  on  one  occasion 
those  changes  in  the  tracheal  sound  which  are  supposed  to 
indicate  the  presence  of  a  very  extensive  deposit  of  false 
membrane,  although  no  false  membrane  was  either  expec- 
torated during  the  patient's  lifetime,  or  discovered  in  the 
inflamed  larynx  or  trachea  after  death.  He  adds  "  we  must 
conclude,  therefore,  that  the  changes  in  the  tracheal  sound 
do  not  afford  absolutely  certain  evidence  of  the  existence  of 
false  membrane,  and  that  still  less  can  they  be  regarded  as 
safe  criterions  of  its  extent."  At  the  commencement  of  the 
disease,  laryngeal  auscultation  simply  reveals  the  character- 
istic stridor,  though  the  air  enters  easily,  and  when  false 
membrane  forms,  the  sound  in  the  larynx  and  trachea  usually 
becomes  less  stridulous  and  more  sibilant,  though,  as  already 
remarked,  there  are  exceptions  to  this  rule.  Barth  and 
Rogers  state  that  when  false  membrane  exists,  tj'cmblotcmcnt 
— a  trembling,  vibratory  murmur — is  present,  and  that  the 
extension  of  this  sound  downward  demonstrates  the  exten- 
sion of  the  disease.  Unfortunately,  the  tremblotcmait  caused 
by    the    presence    of    mucus    in   catarrhal  croup  cannot    be 


PSEUDO-MEMBRANOUS    CROUP.  203 

distinguished  from  the  same  sound  caused  by  the  false 
membrane  of  the  more  malignant  disease.  In  all  cases  the 
information  derived  from  auscultation  must  be  compared  with 
the  vital  symptoms  present,  and  the  course  of  the  disease 
must  be  carefully  investigated. 

During  the  first  stage  the  inspiratory  sound  is  prolonged 
into  a  harsh  and  prolonged  stridor  ;  the  expiratory  sound  is 
also  prolonged  and  harsh,  but  low  in  pitch,  while  the 
weakened  respiratory  murmur  is  effectually  masked  by  the 
shrill,  laryngeal  stridor.  Still,  a  certain  well-defined  mucous 
rhoncus  is  heard  over  the  larger  bronchial  tubes,  especially 
at  the  moment  when  the  child  makes  a  very  deep  inspira- 
tion. No  dullness  on  percussion  is  present,  and  the  entire 
respiratory  movements  are  notably  deficient,  even  at  this 
early  stage,  and  the  walls  of  the  chest  are  never  fully 
expanded.  During  the  second  stage  the  sibilant  inspiration 
is  distinctly  heard  during  sleep,  and  especially  on  waking, 
but  it  has  lost  the  loudness  and  the  persistence  which 
marked  it  during  the  first  stage.  Lastly,  during  the  final 
stage  of  rapidly  advancing  apncea  the  characteristic  tracheal 
sound  is  audible  all  over  the  trachea  during  expiration.  Dr. 
Hartshorne  remarks  that  a  mucous  rale,  sufficiently  tremu- 
lous to  be  audible  without  the  stethoscope,  is  usually  a  very 
favorable  sign,  as  it  almost  invariably  indicates  that  the 
mucous  follicles  are  throwing  out  their  secretion  between 
the  mucous  membrane  and  the  false  membrane — a  process 
on  which  the  cure  at  this  late  stage  greatly  depends. 

The  laryngoscope  can  hardly  be  used  with  croup  patients. 
Even  Steiner,  with  all  his  skill,  is  forced  to  acknowledge  that 
it  is  "  almost  impossible."  Munch  gives  us  the  following 
description  of  his  laryngoscopic  examination  of  a  boy  of  ten 
years  suffering  from  croup  :  "  The  mucous  membrane  of 
the  larynx  was  much  reddened  ;  a  marked  membranous 
deposit  covered  the  aryteno-epiglottidean  ligaments,  and  still 
more  copiously  the  vocal  cords ;  the  glottis  was  narrowed, 
partly  by  the  deposit  on  the  vocal  cords  and  partly  by  the 
paresis  of  the  dilator  muscles — the  posterior  erico-arytenoid. 


204  PSE  I  I><  I  MEMBRANOUS    (  ROl   P. 

Later  the  whole  larynx  appeared  to  be  covered  with 
membrane  ;  at  the  same  time  it  wa's  noticed  that  the  edges 
of  the  vocal  cords  were  apparently  agglutinated  to  each 
other  at  various  points  by  a  layer  of  fluid  exudation. 
Subsequently  the  deposit  disappeared  under  the  continued 
use  of  caustics,  but  was  renewed  daily,  until  finally  only  a 
thin,  gauzy  membrane  was  noticed,  which  returned  again 
and  again  with  great  obstinacy,  especially  upon  the  vocal 
cords.  The  vocal  cords  ultimately  resumed  their  function, 
and  manifested  considerable  vitality,  even  while  some  of 
the  membrane  remained.  By  the  sixteenth  or  eighteenth 
day  the  normal  white  color  of  the  cords  was  restored,  and 
here  and  there  a  reddish  streak  was  all  that  could  be 
noticed." 

Wherein  lies  the  difference  between  the  ordinary  inflamma- 
tion of  mucous  membrane  and  the  exudative  form  of  inflam- 
mation ?  Why  is  it  that  one  child  has,  after  exposure  to 
cold,  a  simple  catarrhal  croup,  while  another,  after  the  same 
exposure,  has  pseudo-membranous  croup  ?  Dr.  Searle  of 
Brooklyn,  remarks,  "  wherever  the  distinction  may  lie 
pathologically,  the  fact  is  certain,"  and  I  shall  endeavor,  as 
correctly  as  may  be,  to  define  the  condition  which  lies  behind, 
not  only  the  symptoms,  but  behind  the  proximate  cause 
which  gives  rise  to  the  symptoms. 

There  is,  then,  an  increased  proportion  of  fibrin,  or  of 
fibro-albuminous  matter  in  the  blood,  and  this  is  considered 
by  Dr.  Cheyne  to  be  analogous  to  the  exudation  of  the 
inflamed  pleura  or  peritoneum.  This  fibrinous  material  has 
a  kind  of  inherent  tendency  to  organization,  and  this  imper- 
fect textural  development  appears  to  set  in  with  the  process 
of  coagulation.  "  Examined  with  the  microscope,  they 
present  a  laminated  basement,  and  one  splitting  into  fibres, 
flattened  or  roundish,  rough  and  firm,  or  resembling  organic 
muscular  fibres  ;  or  else,  a  membranous  basement  invested 
with  delicate,  wavy  fibres,  upon  which,  among  elementary 
granules,  are  seen  numerous  round,  black-edged  nuclei, 
sometimes  rod-shaped,  or  drawn  out  into  fibres,  and  again. 


PSEUDO-MEMBRANOUS    CROUP.  205 

more  especially  in  the  moisture  poured  out,  dull,  round  or 
oval  nuclei,  and  analogous  cells."  (Rokitansky.)  This  first 
variety  of  pseudo-membrane  is  a  tough,  elastic,  polished 
membrane,  quite  similar  to  serous  membrane  in  appearance, 
and  very  like  moist  kid  leather.  At  other  times  the  fibrinoid 
is  of  a  dullish  white  color  inclining  to  yellow,  and  including 
blood-serum  and  blood-corpuscles,  sufficient  to  give  a  reddish 
hue  in  places.  "  Microscopically  examined,  the  coagulum 
presents  a  stratiform  or  fibro-laminated  basement,  or  else  a 
faintly  striated  membrane,  both  being,  however,  opaque, 
owing  to  delicate  granulation.  Upon  this,  as  also  in  the 
serum,  are  seen  a  vast  number  of  nucleus-like  formations  of 
developed,  dull,  granulated  nuclei,  and  of  similar  more  or 
less  developed  cells.  Frequently  the  coagulum  appears  to 
consist  altogether  of  the  two  last-mentioned  elements,  with 
a  proportion  of  granulated  structure."  (Rokitansky.)  Again, 
the  fibrinoid  may  be  pus-like,  of  a  greenish-yellow  hue,  with 
little  tendency  to  organization,  and  but  little  adhesive  power. 
These  three  varieties  rarely  occur  singly  and  alone,  but 
they  are  intermingled  in  varying  proportions.  The  first 
mentioned  is  the  most  dangerous,  as  it  approaches  the  nearest 
to  organization  ;  and  the  last  mentioned  is  analogous  to  the 
matter  of  pyaemia,  for  it  includes  pus-nuclei  and  pus-cells  in 
its  meshes.  The  difference  between  these  varities  of  fibrinoid 
can  be  readily  detected  with  the  naked  eye. 

When  the  mucous  membrane  of  the  larynx  becomes  the 
seat  of  inflammation  or  of  congestion — for  there  can  be  little 
doubt  that  in  croup  the  primary  morbid  change  is  often 
congestion — this  fibrinoid  or  fibro-albuminous  matter  exudes 
from  the  distended  capillaries,  and  the  change  of  temper- 
ature and  the  passage  of  air  over  it  aiding  its  inherent 
tendency  to  imperfect  organization,  it  is  soon  formed  into  a 
false  membrane.  As  the  disease  advances,  the  mucous " 
follicles  secrete  a  copious  muco-purulent,  fluid  which  is 
poured  out  between  the  mucous  membrane  and  the  false 
membrane,  loosening,  the  latter,  so  that  there  is  a  certain 
tendency  toward   recovery  even  in  the  most   severe  forms  of 


206  PS]  I   DO-MEMBRANOUS    CROUP. 

true  croup.     This  congestive  or  inflammatory  action,  with 

its  accompanying  exudation,  may  go  on  undetected  for  some 
little  time  till  the  engorgement  becomes  so  great  as  to  inter- 
fere with  the  passage  of  air  through  the  glottis,  or  till  the  more 
or  less  violent  laryngeal  spasm  directs  attention  to  it.  The 
writer  is  strongly  of  the  opinion  that  while  simple  spasmodic 
croup,  almost  destitute  of  inflammatory  action,  stands  at 
one  end  of  the  scale  of  morbid  action,  at  the  other  extremity 
is  pseudo-membranous  croup,  which  may  be  almost  wholly 
destitute  of  laryngeal  spasm ;  that  though  well-marked 
typical  cases  exist,  which  can  be  readily  diagnosed,  yet  in 
the  middle  of  the  scale  we  find  it  extremely  difficult  to 
decide  as  to  the  presence  or  absence  of  false  membrane  ;  and, 
lastly,  that  a  Case  which  apparently  commences  as  spasmodic 
croup,  may,  under  certain  conditions,  take  on  inflammatory 
action  with  its  attendant  exudation.  The  practical  lesson  is 
to  prescribe  for  even  mild  cases  with  care,  and  constantly  to 
keep  in  view  the  possibility  of  the  occurrence  of  the  much 
dreaded  pseudo-membrane. 

Dr.  Squire  asserts  that  "intense  redness  of  the  mucous 
membrane  is  persistent  after  death,"  but  even  when  the 
redness,  as  observed  by  the  laryngoscope,  has  been  intensely 
bright,  at  the  post-mortem  examination  the  hyperemia  may 
have  entirely  disappeared  or  be  scarcely  noticeable.  Swelling 
is  rarely  found,  as  it,  too,  disappears  with  the  extinction  of 
life,  though  sometimes  the  upper  orifice  of  the  larynx  is 
diminished  by  the  swollen  aryteno-epiglottidean  folds.  Dr. 
Craigie  asserts  that  croupous  inflammation  is  but  seldom 
observed  to  affect  the  laryngeal  mucous  membrane,  and  says 
that  when  it  does  so,  it  is  to  be  viewed  as  a  complication 
not  essential  to  genuine  croup  ;  while,  on  the  other  hand, 
Guersant  says  that  the  characteristic  membrane  is  never 
"entirely  absent  from  the  larynx.  Here  Dr.  Craigie  is  unques- 
tionably in  error,  for  the  larynx  is  always  affected  in  croup, 
though,  as  Rindfleisch  remarks,  a  croupous  inflammation, 
confined  throughout  its  entire  course  to  the  larynx,  is  of  rare 
occurrence. 


PSEUDO-MEMBRANOUS    CROUP.  207 

In  general  terms  it  may  be  said  that  in  two-thirds  of  all 
the  cases  the  disease  is  limited  to  the  larynx  and  trachea, 
while  in  the  remaining  third  the  inflammatory  irritation 
extends  to  the  bronchi ;  though  it  does  not  follow  that  false 
membrane  is  formed  there.  "  The  implication  of  the  trachea 
and  bronchi  is,  at  least  with  us,  very  common  ;  in  fifty-five 
autopsies  of  children  I  found  that  in  thirty-one  the  croup 
had  extended  to  the  larynx,  trachea  and  bronchi,  with  casts 
even  in  the  smaller  tubes;  in  nineteen  the  false  membranes 
were  limited  to  the  larynx  and  trachea  with  purulent  or 
muco-purulent  secretion  on  the  mucous  membrane  of  the 
bronchi,  especially  those  of  the  first  and  second  order ;  in 
the  other  five  cases  croupous  deposits  were  present  only  in 
the  throat  and  larynx,  with  muco-pus  in  the  trachea  and 
bronchi.  It  is  to  be  particularly  noticed  that  in  all  these 
cases  false  membrane  was  demonstrated  in  the  laryngeal 
cavity,  and  it  is  safe  to  say  that  the  absence  of  exudation,  to 
which  some  are  so  ready  to  appeal,  is  unquestionably  the 
very  rare  exception  "'  (Steiner).  Again,  it  may  be  confined 
to  the  glottis  and  it  may  line  the  entire  larynx,  dipping  into 
the  ventricles  so  as  to  form  an  entire  cast  of  the  organ  ;  in 
very  severe  cases  it  extends  to  the  minutest  ramifications  of 
the  bronchial  tubes,  and  this  seems  to  be  more  common  on 
this  continent  than  in  Great  Britain.  Professor  Wood  has 
seen  a  case  in  which  the  false  membrane  lined  the  upper 
portion  of  the  bronchial  tubes,  the  entire  larynx  and  trachea 
and  the  pharynx  as  low  as  the  upper  part  of  the  oesophagus. 
But  the  favorite  situation  of  the  false  membrane  is  on  the 
vocal  cords,  and,  as  a  general  rule,  the  coating  is  thick  in 
proportion  to  the  duration  and  severity  of  the  attack.  Dr. 
Cheyne  compares  the  tubes  of  false  membranes  from  the 
bronchial  tubes  to  macaroni  boiled  in  milk,  and,  in  curious 
anticipation  of  Dr.  Craigie,  he  says  that  in  none  of  the  cases 
seen  by  him  was  membranous  exudation  observed  on  the 
laryngeal  mucous  membrane,  adding,  that  if  the  inflamma- 
tion extended  to  this  part,  it  was  only  slight,  and  its  effects 
were  seen  in  a  little  puriform  fluid  on  the  membrane  of  the 
cricoid  or  thyroid  cartilages. 


2oS  PSE1   I"  i-MEMBR  \\<  >US    CROUP. 

Sometimes  the  false  membrane  adheres  closely  to.  the 
mucous  membrane,  but  it  is  generally  more  or  less  loosened 
from  the  action  of  the  muco-purulent  fluid  already  mentioned, 
and  this  loosening  is,  in  the  words  of  Rindfleisch,  "  a  property 
on  which  all  our  therapeutic  measures,  inadequate  as  they  arc, 
repose!*  After  the  first  membrane  is  thrown  off,  a  second 
succeeds  it,  and  then  a  third,  till  death  takes  place  or 
recovery  ensues  from  the  false  membrane  ceasing  to  form, 
and  when  this  takes  place  it  is  found  that  the  mucous 
membrane  is  but  little  injured,  in  fact  it  is  often  quite 
normal.  There  are  great  differences  in  the  thickness  and 
consistence  of  the  false  membrane  ;  it  is  sometimes  of  a 
gauze-like  tenuity,  while  at  other  times  it  is  one  or  two  lines 
in  thickness,  the  usual*  thickness  being  about  half  a  line  ;  as 
already  mentioned  it  may  be  like  the  viscid  layer  which 
forms  on  the  surface  of  a  bowl  of  cream,  and  it  may  be  a 
tough,  compact,  leather-like  fibrin  resembling  a  fragment  of 
wet  kid  glove.  Almost  invariably,  the  edges  of  the 
membrane  are  thinner  and  softer  than  the  more  central 
portions,  and  the  side  in  contact  with  the  mucous  membrane 
is  softer  than  the  side  exposed  to  the  air.  When  it  extends 
to  the  bronchial  tubes,  Rokitansky  remarks  that  the  tubular 
exudations  from  the  larger  bronchi  present  a  calibre  inversely 
proportional  to  their  thickness,  and  those  thrown  off  from 
the  finer  ramifications  occur  in  solid  cylinders.  Professor 
Wood  remarks  that  in  the  larynx  it  is  said  to  be  less  firm 
than  in  the  trachea  ;  while  Professor  Gross  asserts  that  it  is 
generally  much  stronger,  more  tenacious,  and  more  firmly 
adherent  in  the  larynx  than  in  the  trachea  and  bronchial 
tubes.  "  The  characteristic  feature  in  the  morbid  anatomy 
of  laryngeal  croup  is  due  to  the  fact  that  the  mucous  lining 
of  the  larynx  agrees  in  its  structure,  partly  with  that  of  the 
pharynx,  partly  with  that  of  the  trachea.  Both  surfaces  of 
the  epiglottis,  and  the  true  vocal  cords,  are  coated  with  a 
laminated  pavement-epithelium,  which  is  not  marked  off 
from  the  connective  tissue  by  any  homogeneous  basement- 
membrane.     Hence,  the  false  membranes  adhere  more  firmly 


PSEUDO-MEMBRANOUS    CROUP.  209 

to  these  than  to  any  other  points  in  the  interior  of  the 
larynx.  How  often  do  we  find,  in  making  a  post-mortem 
examination,  that  the  tracheal  false  membrane,  continuous 
with  that  of  the  laryngeal  funnel,  is  quite  loose  as  far  up  as 
the  rima  glottidis,  where  it  is  firmly  attached  ;  and  we  feel 
sure  that  its  spontaneous  detachment  at  this  point  would 
have  required  a  very  long  time  for  its  accomplishment." 
(Rindfleisch.)  The  color  of  the  denser  membrane  is  of  a 
pearly,  grayish  white,  while  the  more  diffluent  membrane  is 
of  a  yellowish  white. 

Small  quantities  of  carbonate  of  soda  and  phosphate  of 
lime  have  been  detected  in  the  false  membrane,  and  it  is 
soluble  in  acetic  acid  and  alkaline  solutions,  especially  in 
lime  water ,  in  short,  in  all  its  chemical  relations  it  closely 
resembles  coagulated  fibrin.  Examined  microscopically, 
according  to  Steiner,  it  is  found  to  be  composed  of 
amorphous  or  fibrillated  fibrin,  in  which  numerous  young 
cells  are  entangled.  Squire  says  that  it  is  not  simply  fibrin, 
but  that  "  it  consists  of  effused  lymph,  in  which  the  presence 
of  albumen  can  always  be  chemically  demonstrated  ; 
microscopically  it  is  a  mass  of  cystoid  corpuscles." 

Is  the  false  membrane  susceptible  of  organization? 
Generally  speaking,  it  gives  no  indication  of  such  an  attri- 
bute, and  yet  Rokitansky  thinks  that  an  effort  at  organiza- 
tion occasionally  takes  place.  "  The  surface  next  to  the 
mucous  membrane  is  frequently  marked  with  red  streaks  and 
dots,  consisting  in,  part  of  blood  adhering  to  the  surface,  and 
in  part,  as  found  on  closer  examination,  of  straight  or 
tortuous  vessels,  or  of  small,  roundish,' extravasations,  from 
which  currents  of  blood  are  seen  to  emerge  in  an  arborescent 
and  radiating  form."  Professor  Hasse  remarks  that  the 
effort  at  assimilation  is,  in  some  instances,  very  perceptible 
in  the  appearance  of  stellated  ecchymoses  and  bloody  streaks 
on  the  surface  of  the  false  membrane,  facing  the  mucous 
membrane. 

The  mucous  membrane  subjacent  to  the  false  membrane 
seldom    presents    the    appearance    of    severe    inflammation, 


210  PSEUD*  l-MEMBR  \\<  »US    CR01   P. 

though  it  may  be  red,  purple,  or  even  blackish  in  color,  and 
these  tints  are  in  spots  or  patches,  which  are  sometimes 
arranged  in  irregular  stripes.  The  mucous  membrane  is 
sometimes,  but  rarely,  in  a  state  of  gelatinous  softening,  and 
thickening  is  still  more  rare.  West  has  observed  ulceration 
in  one  acute  case,  but  frequently  in  cases  of  secondary 
croup,  probably  diphtheria.  But,  on  the  whole,  the  mucous 
membrane  producing  the  croupous  membrane  remains,  as 
Squire  remarks,  "  singularly  free  from  pathological  injury." 
At  an  advanced  period  of  the  disease  the  redness  may 
disappear,  when  the  mucous  membrane  regains  its  usual  pale 
color.  The  trachea  and  bronchial  tubes  are  usually  red- 
dened, even  though  the  disease  has  not  extended  to  them, 
and  the  bronchial  tubes  contain  a  yellowish,  puriform  fluid, 
which  has  doubtless  passed  downward  from  the  seat  of 
morbid  action.  A  certain  degree  of  pulmonary  congestion 
is  an  almost  inevitable  result  of  croup,  and  the  same  may  be 
said  of  the  vesicular  emphysema,  which  results  from  the 
extraordinary  efforts  to  breathe,  which  sometimes  brings  on 
laceration  of  the  pulmonary  vesicles.  The  same  desperate 
respiratory  efforts  often  cause  congestion  of  the  brain  and 
even  effusion  of  serum  into  the  ventricles. 

To  those  physicians  who  believe  that  there  is  but  one 
kind  of  croup,  clearly  but  little  diagnosis  is  necessary.  Thus 
the  celebrated  Dr.  Dewees  speaks  of  "  a  distinct  species  of 
croup,  namely  :  the  spasmodic,  a  kind  we  have  never 
witnessed,"  though  Drs.  Meigs  and  Pepper,  who  practice  in 
the  same  city  that  was  honored  by  the  residence  of 
Dr.  Dewees,  declare  that  they  meet  with  six  cases  of 
spasmodic  croup  for  one  of  pseudo-membranous.  Again, 
Dr.  Robert  C.  R.  Jordan,  Professor  of  Diseases  of  Children, 
Queen's  College,  Birmingham,  England,  writes  as  follows  : 
"  In  all  my  own  early  teaching  it  was  strongly  impressed 
upon  me  that  "croup"  was  always  a  membraneous  exudation 
in  the  larynx  or  trachea,  that  it  became  to  my  mind  a  great 
difficulty  to  throw  off  the  trammels  of  this  old  belief,  and  it 
was  long  before  I  could  feel  fully  persuaded  of  what  I   now 


PSEUDO-MEMBRANOUS    CROUP.  211 

know  to  be  the  truth — namely,  that  the  majority  of  the 
cases  usually  called  by  this  name  have  no  false  membrane 
formed  at  all,  but  that  their  essential  nature  is  an  inflamma- 
tion of  the  mucous  membrane  of  the  larynx  and  trachea, 
accompanied  with  secretion  of  tenacious  mucus,  and  also 
considerable  swelling  caused  by  effusion  into  their  sub- 
mucous areolar  tissue.  They  are,  in  fact,  catarrhal  inflam- 
mations of  the  larynx  and.  trachea.  All  other  cases  where 
exudation  is  really  present  are  diphtheria  ;  and  it  is  in  this 
sense  and  with  this  definition  only  that  we  can  regard  croup 
and  diphtheria  as  two  distinct  diseases." 

The  diagnosis  between  pseudo-membranous  croup  and 
catarrhal  croup  will  be  found  in  ChapterV,  that  between  croup 
and  spasm  of  the  glottis  in  Chapter  IV.  It  remains,  then, 
to  give  the  diagnosis  between  spasmodic  croup  and  pseudo- 
membranous croup,  for  a  diagnosis  can  certainly  be  made  in 
spite  of  the  confident  assertion  of. Dr.  Maunsell  that  "  there 
are  no  means  of  distinguishing  between  the  two  affections 
(if  two  distinct  affections  exist),  beyond  the  degree  of 
violence  of  the  symptoms." 

The  attack  of  spasmodic  croup,  then  is,  as  a  general  rule, 
sudden  and  startling,  while  the  invasion  of  pseudo-membra- 
nous croup  is  insidious  and  creeping.  In  spasmodic  croup 
the  voice  is  hoarse  but  never  whispering,  save  during  the 
height  of  the  attack,  while  in  pseudo-membranous  croup, 
the  voice,  at  first  hoarse,  soon  becomes  whispering,  and 
finally  is  entirely  lost.  The  cough  of  spasmodic  croup  is 
rough  and  hoarse'throughout,  while  in  pseudo-membranous 
croup  the  cough  is  rough  and  hoarse  at  first,  infrequent 
further  on,  and  finally  is  quite  suppressed.  In  spasmodic 
croup  the  suffocative  attacks  generally  occur  at  the  begin- 
ning of  the  disease,  in  pseudo-membranous  croup  they  come 
on  at  an  advanced  stage.  In  spasmodic  croup  great 
dyspncea  is  very  rare  and  it  never  persists,  but.  in  pseudo- 
membranous croup  dyspncea  is  an  essential  feature  of  the 
disease.  The  respiration  of  spasmodic  croup  is  stridulous 
and  difficult  only  during  the  paroxysm,  but  almost  natural 


•i  !  I'M  I   hi  .  MEMBRANOUS    CR<  H   I 

in  the  interval,  while  in  pseudo-membranous  croup  the 
respiration,  at  first  almost  normal,  becomes  very  nearly- 
permanent  ly  stridulous.  In  spasmodic  croup  the  fauces  are 
quite  clean  or  a  slight  redness  may  be  present,  but  in  pseudo- 
membranous croup  a  fibrinous  exudation  is  quite  common. 
In  spasmodic  croup  the  fever  is  very  slight  and  may  be 
altogether  absent,  and  it  may  only  appear  during  the 
paroxysm,  while  in  pseudo-membranous  croup  the  fever  is 
quite  high.  After  the  paroxysm  of  spasmodic  croup  the 
child  is  quite  well  and  the  fever  departs,  but  after  the  first 
paroxysm  of  pseudo-membranous  croup  the  child  is  quite  ill, 
with  high  fever,  stridulous  breathing  and  hoarse  cough.  If 
the  paroxysm  of  spasmodic  croup  returns  the  second  night 
it  is  less  severe  than  it  was  the  previous  night,  but  the 
second  nocturnal  paroxysm  of  pseudo-membranous  croup 
has  increased  dyspnoea  and  threatening  suffocation.  Spas- 
modic croup  rarely  lasts  more  than  three  days,  and  good 
treatment  reduces  this  to  thirty-six  or  forty-eight  hours,  and 
it  is  not  followed  by  hoarseness,  while  pseudo-membranous 
croup  is  rarely  of  shorter  duration  than  five  or  six  days, 
and  hoarseness  is  apt  to  continue  for  two  or  three  weeks. 
A  child  may  have  repeated  attacks  of  spasmodic  croup,  but, 
as  a  general  rule,  true  croup  does  not  recur.  Lastly, 
spasmodic  croup  is  hardly  ever  fatal,  while  pseudo-membra- 
nous croup,  in  spite  of  the  best  treatment,  is  frequently 
fatal. 

Pseudo-membranous  croup  is  always  a  serious  disease,  but 
the  homoeopathic  physician  need  not  assent  to  Vogel's 
maxim,  "  the  prognosis  in  well-declared  croup  may  be  set  down 
as  fatal,"  or  even  to  Sir  Thomas  Watson's  well-known 
dictum,  "the  prognosis  can  never  be  better  than  doubtful" 
though  that,  after  all,  is  merely  the  legitimate  result  of  a 
treatment  comprehending  blood-letting,  tartarized  antimony 
and calomel \  said  by  the  last-mentioned  eminent  authority  to 
be  "the  remedies  that  most  require  consideration."  Almost 
all  physicians — especially  those  of  European  education  and 
experience — will  assure  you  that,  under  any  circumstances,  a 


PSEUDO-MEMBRANOUS    (ROUP.  213 

majority  must  die,  but  with  a  thorough  knowledge  of  the 
pathology  of  the  disease  and  of  the  admirable-  therapeutic 
agents  which  homoeopathy  places  at  our  disposal,  the  writer 
believes  that  a  majority  will  live. 

Guersant  says  that  it  is  "generally  fatal,"  adding  that  it  is 
scarcely  possible  to  save  two  in  ten,  while  Rilliet  and  Barthez 
state  that  "its  common  termination  is  in  death."  Steiner 
thinks  that  the  prognosis  is  "almost  always  dismal,  a  fatal 
result  being  almost  the  rule,  for  in  tracheotomy  alone  there 
seems  any  chance  of  recovery."  Felix  von  Niemeyer 
considers  it  "  one  of  the  most  formidable  of  diseases,"  and 
Squire  thinks  that  "the  slightest  cases  of  croup  furnish  grave' 
cause  for  anxiety."  Maunsell  is  almost  the  only  writer  who 
takes  a  really  cheerful  view  of  the  matter,  and  he  affirms 
that  "  it  is  remarkably  within  the  control  of  art  " — very  true 
of  spasmodic  croup,  but  not  quite  so  true  of  pseudo- 
membranous croup.  Dr.  Squire  speaks  of  "  the  hopeful 
conjecture  of  Dr.  Wood,  of  Philadelphia,  that  one  case  in 
fifty  only  is  fatal,"  but  Dr.  Squire  overlooks  the  fact  that  the 
great  Philadelphian  is  speaking  of  the  "  ordinary  croup  of 
this  country,"  which  is  catarrhal  and  spasmodic  in  its  nature. 
Meigs  and  Pepper  lost  sixteen  out  of  thirty-five  cases, 
though  they  have  attended  two  hundred  cases  of  spasmodic 
croup  without  a  death. 

The  danger  is  great  in  proportion  to  the  youth  of  the 
patient.  A  child  a  year  old  has  less  chance  than  one  of  five 
years,  and,  as  already  stated,  the  disease  is  more  fatal  in 
boys  than  in  girls.  Vogel's  experience  is  that  children  who 
have  passed  their  seventh  year  may  survive  attacks  of 
croupous  laryngitis  of  the  utmost  intensity. 

Very  much  depends  upon  the  stage  of  the  disease  at 
which  the  patient  comes  under  treatment,  and  quite  as  much 
depends  upon  the  physician  possessing  an  accurate  knowl- 
edge of  the  disease  before  him.  If  no  efficient  treatment  is 
adopted  till  the  disease  is  fully  developed  and  the  false 
membrane  formed,  the  prospect  of  cure  is  much  diminished  ; 
but     if,    on     the    other    hand,    it    is    recognized    from    the 


214  PSE1  DO-MI  Mi;i;  \\<  »1  S    CR<  >1  P. 

commencement,  and  skilful  medical  attendance  is  joined  to 
careful  nursing,  the  chances  of  recover}-  are  better.  Pneu- 
monia aggravates  the  danger,  and  when  the  bronchi  become 
implicated  in  the  disease,  the  prognosis  is  very  grave,  though 
it  is  well  to  remember  that  in  bronchial  croup  the  membrane 
is  less  firmly  adherent  than  in  the  laryngeal  and  tracheal 
forms.  Although  the  general  symptoms  should  be  duly 
weighed,  especial  attention  should  be  paid  to  the  local 
symptoms,  and  to  the  frequency  of  the  paroxysms.  It  is 
unfavorable  if  the  stridulous  sound  is  heard  both  in  inspira- 
tion and  expiration,  and  complete  extinction  of  the  voice 
and  suppression  of  the  cough  are  most  ominous  signs.  Sir 
Thomas  Watson  remarks,  "  we  begin  to  despair  when  the 
lips  are  turning  blue,  the  skin  is  losing  its  heat,  the  pulse  is 
already  feeble  and  intermitting,  and  the  little  patient  is 
drowsy  or  comatose."  On  the  other  hand,  the  favorable 
signs  are  diminution  of  the  stridulous  respiration  ;  return  of 
the  voice,  even  though  it  be  hoarse  ;  looseness  of  the  cough 
with  expectoration  of  muco-purulent  matter  mingled  with 
fragments  of  false  membrane  ;  and  decrease  of  the  dyspnoea. 
Dr.  Meadows  observes  that  "sometimes  just  as  the  active 
signs  of  the  attack  are  subsiding,  a  relapse  takes  place,  and 
the  condition  becomes  a  much  more  alarming  one ;  this 
tendency  to  relapse  should  make  our  prognosis  guarded  for 
at  least  two  or  three  weeks,  and  particularly  in  weak,  delicate 
and  irritable  children."  In  like  manner,  Dr.  Charles  West 
says  that  much  caution  must  be  exercised  in  drawing  a 
favorable  conclusion  from  a  diminution  of  the  severity  of  the 
symptoms,  until  such  improvement  has  continued  for  twenty- 
four  hours  at  least ;  and  I  can  most  cordially  endorse  Dr.  J. 
F.  Meigs'  axiom,  "  the  case  should  not  be  abandoned  as 
hopeless  until  life  is  actually  extinct."  Very  cheering,  too, 
are  the  words  of  Maunsell,  "children  have  recovered  from 
the  most  hopeless  condition,  and  we  should  never  despair  of 
a  sick  child." 

Children  who  show  any  tendency  to  croup  should  not  go 
out  of  doors  when    cold  east   winds  are  blowing,  and  when 


PSEUDO-MEMBRANOUS    CROUP.  215 

such  children  go  out,  even  in  moderately  cold  weather,  they 
should  be  warmly  and  comfortably  clad,  especially  about 
the  feet  and  neck.  In  addition  to  this  precaution  the  neck 
and  chest  should  be  systematically  sponged  with  cold  water 
every  morning,  and  in  addition,  gargles  of  cold  water  should 
be  used  two  or  three  times  a  day. 

At  the  first  faint  hint  of  croup  in  the  voice,  respiration  or 
cough,  I  have  seen  singularly  good  results  from  the  application 
of  a  sponge  dipped  in  hot  water — as  hot  as  the  child  will  bear 
— directly  over  the  larynx  and  trachea.  The  sponge  should 
be  well  squeezed  out,  refilled  and  again  applied  every  two  or 
three  minutes,  for  say  half  an  hour.  At  the  same  time, 
steps  should  be  taken  to  secure  a  warm,  moist  and  uniform 
atmosphere  for  the  little  patient,  in  fact,  as  Dr.  Prosser 
James  urged,  many  years  ago,  "  the  patient  should  be  kept, 
as  it  were,  in  a  vapor  bath,"  and  of  temperature  too,  much 
higher  than  is  usual  in  any  sick  chamber.  The  temperature 
should  be  kept  from  jo°  to  75°,  and  I  have  kept  it  at 
8o°  for  two  or  three  days  with  excellent  results.  In  order  to 
accomplish  this  it  will  be  necessary  to  make  a  so-called 
'  croup-tent  :  around  the  child's  bed,  behind  that  tent  a  kettle 
of  boiling  water  is  placed  on  a  spirit  lamp,  and  the  steam 
from  the  kettle  is  thrown  into  the  tent  by  means  of  a  long 
tin  spout.  But  ventilation  must  be  seen  to,  for  fresh  air  is 
just  as  much  a  necessity  as  warm,  moist  air,  and  without 
fresh  air  the  croup-tent  would  be  a  positive  nuisance.  I  do 
not  recommend  the  warm  bath,  believing  with  Cheyne  that 
"the  warm  bath  is  a  very  equivocal  remedy."  The  diet 
should  be  bland  and  mucilaginous  throughout  the  illness, 
though  well-made  beef-tea  in  small  quantities  is  always  in 
place. 

I  incline  to  think  that  medical  men  of  our  school  look 
with  a  less  favorable  eye  on  tracheotomy  than  do  their 
brethren  of  the  dominant  medical  faith.  The  chief  cause 
of  this  seems  to  be  the  great  reliance  which  we  justly 
place  upon  our  therapeutic  agents,  and  hence,  Baehr,  our 
best  systematic  writer,  summing  up  the  resources  of  the  old 


!l6  I'Si'i  DO  Ml  M  i :  I :  \\i  il  s    cki  >ui\ 

school  against  true  croup,  says:  "  In  spite  of  all  these 
appliances,  from  70  to  90  per  cent,  of  all  undoubted  cases  of 
membranous  croup  perish.  This  result  is  certainly  no 
triumph,  nor  has  tracheotomy  increased  tin-  chances  of 
recovery." 

Home  first  suggested  tracheotomy  in  his  classic  work  on 
croup,  in  the  year  i/<">5,  though  he  never  performed  the 
operation.  In  the  year  17x2,  a  London  surgeon  named 
John  Andre  secured  the  honor  of  the  first  operation,  at  all 
events,  his  is  the  first  recorded  case.  In  1818  the  celebrated 
Bretonneau  revived  the  operation,  but  his  patient  died  and 
the  same  result  followed  a  second  attempt  six  .years  later. 
As  an  epidemic  of  diphtheria  was  raging  at  the  time — the 
epidemic,  in  fact,  in  which  Bretonneau  won  such  imperishable 
laurels — it  is  highly  probable  that  these  were  diphtheria 
patients,  hence  the  fatal  result,  for  in  the  language  of  Dr. 
A.  W.  Barclay,  "  tracheotomy  is  certainly  more  adapted  to 
this  disease  (pseudo-membranous  croup)  than  to  diphtheria, 
in  so  far  as  the  attack  is  local  instead  of  constitutional,  is  an 
inflammation  instead  of  a  blood-poisoning."  In  1825, 
Bretonneau  again  attempted  the  operation,  this  time  with 
success,  and  following  his  lead,  Trousseau,  for  a  time,  saved 
half  his  patients,  though  the  average  of  recoveries  seems  to 
have  been  about  one-fourth  of  the  whole  number  of  cases. 

The  older  English  practitioners  had  but  little  confidence 
in  tracheotomy.  Cheyne  never  approved  of  it,  and  argued 
against  it  with  a  good  deal  of  skill,  and  he  had  very  great 
weight  with  the  English  practitioners  almost  down  to  our 
own  day.  Copland  gives  a  resume  of  treatment,  including 
bleeding,  emetics,  purgatives,  sudorifics,  expectorants,  anti- 
spasmodics, calomel,  blisters  and  baths,  concluding  with 
Valentin's  famous  recommendation,  "  the  application  of  the 
actual  cautery  upon  each  side  of  the  throat,  in  the  most 
severe  forms  of  the  disease,  when  it  is  at  its  acme,"  to  which 
the  distinguished  author  of  the  Dictionary  of  Practical 
Medicine  adds,  "  there  does  not  seem  to  be  a  chance  from 
this  operation  in  any  case  wherein  the  treatment  developed 


PSEUDO-MEMBRANOUS    CROUP.  21 J 

above  has  failed."  Certainly,  after  the  patient  has  been 
subjected  to  the  destructive  art  of  healing  as  exemplified  by- 
such  a  course  of  treatment,  he  would  be  most  unlikely  to 
possess  sufficient  vitality  for  tracheotomy  or  any  other 
operation.  The  older  practitioners  on  this  continent 
sympathized  with  their  English  brethren  in  this  matter. 
Dr.  Dewees  was  very  strongly  opposed  to  it ;  Dr.  Physick 
had  no  confidence  in  it,  and  the  operation  was  little  used 
till  a  new  generation  of  practitioners  arose  who  leaned  less 
on  authority  and  more  on  personal  experience. 

Greve  places  the  mortality  in  Sweden  at  23  per  cent.; 
Trousseau  at  50;  Franquet  at  68;  Bricheteau,  who  draws  a 
sharp  line  between  diphtheritic  and  true  croup,  gives  the 
mortality  from  the  latter  as  69  per  cent.  Steiner  endorses 
the  operation,  yet  he  says  :  "  The  proportion  of  recoveries 
is  stated  by  all  writers  of  honesty  and  diagnostic  skill  as 
lamentably  small.  Out  of  quite  a  large  number  of  cases 
occurring  in  my  practice,  before  I  had  adopted  the  operation  of 
tracJicotomy,  I  saw  but  three  recoveries;  since  1863,  however, 
this  discouraging  rate  has  been  so  much  improved  by  the 
employment  of  tracheotomy  that  the  mortality  has,  at 
different  times,  amounted  only  to  sixty,  sixty-five  and  seventy 
per  cent." 

French  physicians  have  employed  tracheotomy  with 
marked  success,  so  much  so  that  one  feels  morally  certain 
that  all  their  patients  could  not  have  been  blood-poisoned, 
diphtheritic  ones,  but  that  many  of  them  must  have  suffered 
from  pseudo-membranous  croup,  and  their  success  arose  from 
the  fact  that  they  operated  in  the  early  and  hopeful  stage  of 
the  disease,  while  the  English,  till  very  lately,  seldom 
resorted  to  it  till  the  case  was  hopeless.  Furthermore,  I 
believe  that  there  are  cases,  not  very  many  it  is  true,  of  this 
disease,  in  which  tracJieotomy  offers  the  only  chance  of  life — 
I  allude  to  the  foudroyante  cases,  in  which  the  disease 
marches  on  to  a  fatal  issue,  unchecked  by  the  best  selected 
remedies.  In  these  cases  the  only  safety  lies  in  the  prompt 
and  skillful  use  of  the  knife. 


2l8  PSEUDO-MEMBRANOUS    CROUP. 

Tracheotomy  does  not  increase  the  risk  of  a  fatal  issue, 

and  personally  I  am  almost  of  opinion  that  the  operation  is 
justifiable  it  only  to  secure  euthanasia.  The  operation  has 
been  but  little  employed  by  the  homoeopathic  practitioners 
of  this  continent,  partly  because  the  disease  is  comparatively 

rare,  and  partly  because,  as  already  remarked,  we  have  a 
thorough  knowledge  of  better  remedies. 

In  the  fust  stage  of  pseudo-membranous  croup,  I  consider 
Aconite  beyond  all  question  the  leading  remedy,  for  it  corre- 
sponds not  merely  to  the  symptomatic  appearances,  but  it 
combats  the  very  inmost  essence  of  the  disease.  In  addition 
to  the  indications  given  in  the  chapter  on  spasmodic  croup, 
I  would  add  the  following,  by  the  venerable  and  beloved 
Charles  Julius  Ilempel,  who  ma)-  justly  be  said  to  have 
stamped  the  peculiar  impress  of  his  mind  on  the  homoeo- 
pathy of  this  continent:  "In  Membranous  Laryngitis,  or 
Croup,  Aconite  is  often  sufficient  to  arrest  the  inflammatory 
process  which  is  going  on  in  the  lining  membrane  of  the 
larynx,  or  to  promote  its  absorption.  More  than  one 
symptom  among  the  symptoms  of  Aconite  points  to  its  use 
in  croup  as  a  specific  remedy.  Among  the  Aconite  symptoms 
we  have  hoarseness,  croaking  voices,  feeble  voice,  complete 
loss  of  voice,  sensitiveness  of  the  larynx  to  the  inspired  air 
as  if  the  mucous  membrane  were  deprived  of  the  epithelium, 
sensation  as  if  the  sides  of  the  larynx  were  pressed  together. 
These  and  similar  symptoms,  together  with  the  dry,  hard 
and  tearing  cough  which  Aconite  excites,  and  the  raw  feeling 
in  the  larynx  during  the  paroxysm  of  cough,  are  strikingly 
characteristic  indications  for  the  use  of  Aconite  in  croup." 

Dr.  Elb  advances  the  following  views:  "Aconite,  as  a 
medicine  corresponding  to  the  local  affection  and  the  accom- 
panying fever,  must  be  a  perfectly  appropriate  remedy,  and 
this  is  corroborated  by  experience.  Hut  as  other  character- 
istic symptoms  are  peculiar  to  croup,  such  as  the  deposition 
of  the  exudation,  it  is  evident  that  Aconite  cannot  suffice 
for  all  cases  or  stages,  and  hence  that  its  applicability  is 
limited.     Experience    teaches    us    that    it    is    of    use    when 


PSEUDO-MEMBRANOUS    CROUP.  219 

inflammation  is  still  present  and  accompanied  by  fever,  with 
hard,  full,  frequent  pulse,  and  when  there  is  great  anxiety 
and  rough  respiration.  It  will  accordingly  be  chiefly  suitable 
for  the  beginning  of  the  disease,  a  view  in  which  not  only 
all  practitioners  are  agreed,  but  this  is  often  laid  down  as  the 
sole  indication."  Riickert  writes,  "Aconite,  in  fine,  should 
always  be  administered  in  the  inflammatory  stage  ;  it  thereby 
assists  the  action  of  the  next  remedy  indicated."  Baehr 
teaches  as  follows:  "If  we  are  called  to  a  case  of  croup  in 
the  night,  it  is  not  always  possible  to  at  once  obtain  the 
conviction  that  we  are  dealing  with  a  case  of  croup ;  for 
even  the  presence  of  considerable  dyspnoea  does  not  always 
imply  that  the  disease  before  us  is  croup.  In  order  to  meet 
this  uncertainty  the  custom  has  prevailed  for  a  long  time 
already  to  at  once  give  Aconite  in  alternation  with  some 
other  remedy.  We  do  not  approve  of  this  custom  of  giving 
remedies  in  alternation,  but  make  an  exception  in  favor 
of  croup  on  account  of  the  uncertainty  in  our  diagnosis. 
Aconite  is  excellent  in  catarrhal,  but  utterly  inefficient  in 
membranous  croup.  If  we  suspect  a  case  of  membranous 
croup,  we  give  Aconite  2,  and  Iodium  2,  in  alternation  every 
hour."  Hughes  writes,  "Whatever  medicine  you  choose,  I 
recommend  to  alternate  it  with  Aconite.  Croup  is  a  neuro- 
phlogosis,  and  the  spasmodic  paroxysms  need  as  much  help 
as  the  continuous  inflammation."  Ba;hr  and  Hughes  are 
undoubtedly,  at  the  present  time,  the  leading  homoeopathic 
writers  of  their  respective  countries,  and  yet  in  opposition 
to  their  authority,  I  would  advise  Aconite,  and  all  other 
remedies,  to  be  given  singly  and  alone.  For  many  years  I 
alternated  remedies,  and  my  practice  remained  destitute  of 
a  sound  experience.  At  length,  in  the  Fall  of  1869,  I  made 
a  tour  through  the  Western  States,  when  I  noted  that  nearly 
all  the  practitioners  who  alternated  were  strongly  disposed 
to  mix  medicines.  Finally,  the  crisis  came  when  a  distin- 
guished physician  advised  me  to  take  equal  quantities  of 
Leptandrin  1,  Podophyllin  1,  and  Mercurius  solubulis  r, 
triturate  them  together,  and  give  this  highly-scientific  prepa- 


220  PSEUDO-MEMBRANOUS    CROUP. 

ration  in  five-grain  doses  three  times  a  day  as  a  panacea  for 
"  liver  complaint."  I  returned  home  and  never  alternated 
more.  Since  that  time  1  have  adhered  unswervingly  to  the 
single  remedy,  and,  while  I  have  had  vastly  better  results,  I 
have  gradually  attained  to  such  an  insight  into  therapeutics 
as  I  never  could  while  wandering  in  the  quagmire  of  alter- 
nation. Give  but  cue  remedy.  Should  that  cease  to  be 
indicated  select  another,  but  never  alternate. 

Ruddock,  following  in  the  wake  of  Hughes,  says:  "  Even 
when  another  medicine  is- indicated  it  is  often  advisable  to 
administer  Aconite  in  alternation  to  relax  the  spasm  which 
often  complicates  the  disease." 

"  A  child  three  years  old  ;  severe  croup  ;  at  the  point  of 
suffocating.  Aconite  i,  one  drop  in  a  glass  half  full  of  water, 
a  teaspoonful  every  quarter  of  an  hour.  After  a  few  doses 
profuse  perspiration  broke  out  and  the  child  was  saved." 
(Dr.  A.  Crica.) 

"  A  fat,  healthy  child,  aged  two  years,  was  taken  suddenly 
with  croup  after  an  exposure  to  a  dry,  cold,  west  wind. 
Face  and  skin  burning  hot  ;  wants  to  drink  constantly  ; 
agonized  expression  ;  constant  restlessness ;  aggravation 
after  sleeping.  Aconite  200,  two  doses  half  an  hour  apart, 
cured."     (Hoyne.) 

In  this  disease  I  have  confined  myself  to  the  use  of  the 
tincture  of  the  fresh  root,  or  the  first  and  second  decimal 
dilutions  of  the  same  preparation,  from  two  to  five  drops  in 
a  tumblerful  of  water,  a  teaspoonful  every  half  hour,  or  even 
every  fifteen  minutes.  I  am  aware  that  I  have  been  cen- 
sured for  recommending  the  use  of  mother  tinctures  and  low 
dilutions,  but  I  would  remark  that  1  am  not  giving  the 
experience  of  my  censors,  but  my  own.  Very  much  more 
important  than  an  adherence  to  the  high  potencies  is  a 
thorough  knowledge  of  pathology  and  pathological  anatomy, 
and  a  little  of  the  eloquence  directed  against  the  low 
dilutions  would  not  be  thrown  away  if  it  were  turned  against 
the  polypharmacy  and  alternationism  and  isopathy  which 
threaten  to  engulf  our  school. 


PSEUDO-MEMBRANOUS    CROUP.  221 

Iodine  is  a  remedy  upon  which  many  physicians  rely  in 
this  disease,  though  Kreussler,  an  excellent  therapeutist,  says 
that  "  he  does  not  recommend  it,  as  our  provings  upon  the 
healthy  do  not  seem  to  point  to  Iodine  as  a  remedy  for 
croup."  It  was  introduced  as  a  remedy  for  pseudo-membra- 
nous croup  by  Koch  in  1841,  and  since  that  date  Spongia 
has  lost  its  position  and  is  now  only  used  in  the  less  danger- 
ous catarrhal  and  spasmodic  croups.  Koch  reports  that  he 
gave  Iodine  alternately  with  Aconite  in  thirteen  cases  of 
croup,  all  of  which  he  affirms  were  pseudo-membranous,  with 
such  success  that  none  died  ;  but,  as  a  writer  in  the  Neues 
ArcJiiv.  points  out,  "  the  result  does  not  speak  decidedly 
enough  in  favor  of  Iodine,  for  a  second  remedy,  often  of 
essential  service  in  croup,  was  always  given  in  alternation." 
Still,  the  same  writer  admits  that  in  a  patient  affected  with 
stenosis  of  the  larynx,  Iodine  produced  the  most  frightful 
suffocative  symptoms  and  a  sound  like  the  most  violent 
croup,  and  he  adds  that  four  cases  of  the  cure  of  croup  by 
Iodine  are  recorded  by  Tietze  in  the  Neues  Archiv.,  vol.  I. 

Both  Elb  and  Baehr  urge  us  to  give  Iodine  from  the  very 
inception  of  the  disease.  Elb  writes :  "  given  at  the  first 
onslaught  of  the. disease  it  is  calculated  to  cut  short  the  whole 
malady  ;  "  and  Bsehr  thinks  that  "  there  is  no  reason  why  a 
medicine  that  embraces  in  its  pathogenetic  series  all  the 
symptoms  of  croup,  and  must  therefore  be  adapted  to  every 
stage  of  this  disease,  should  not  be  given  at  the  very 
commencement  of  the  attack."  Elb  alternates  Iodine  with 
Aconite — indeed  it  seems  to  be  almost  impossible  to  get 
practitioners  to  confide  in  one  single  remedy  in  this  disease 
— and  even  Baehr,  usually  a  single-remedy  man,  apologeti- 
cally says,  that  "  we  do  not  approve  of  this  custom  of  giving 
remedies  in  alternation,  but  make  an  exception  in  favor  of 
croup  on  account  of  the  uncertainty  in  our  diagnosis." 
"  Like  the  sudden  subsidence  of  a  storm,"  writes  Elb,  "so 
wonderfully  quick  is  the  action  of  this  first  dose,  if  the  dose 
was  not  too  strong,  the  anxiety  and  imminent  suffocation 
and  whistling  cough  cease,  as  if  by  magic,  and  the  dyspnoea 


222  PSEUDO-MEMBR  \\<>i  g    CROl  P. 

becomes  so  much  diminished  that  we  may  safely  wait  an 
hour  before  giving  a  dose  of  Aconite  ;  this  speedily  procures 
a  remission  of  the  fever,  with  the  breaking  out  of  a  beneficial 
perspiration  ;  the  danger  is  g<  nerally  past  in  a  few  hours, 
notwithstanding  which  pause  it  is  not  advisable  to  leave  off 
the  medicines  too  soon,  seeing  that  the  disease  can  only  be 
suppressed  and  kept  down  by  these  means  ;  for  which 
reason  I  continue  the  use  of  Iodine  and  Aconite  alternately 
every  hour,  even  during  sleep,  until  the  breathing  is  no 
longer  sawing  and  the  cough  has  become  looser,  after  that 
only  every  two  or  three  hours;  in  this  way  the  transition  to 
an  ordinary  catarrh  is  effected,  and  recovery  takes  place." 
Hempel,  in  his  work  on  Practice,  places  most  reliance  on 
Aconite  and  Spongia,  adding  :  "  If  Spongia  seems  powerless 
and  the  spasmodic  wheezing  continues,  we  must  try  Iodine." 
Hughes  considers  Iodine  "our  chief  remedy  in  true  croup," 
and  adds  that  "the  medicines  between  which  our  choice  lies 
are  Iodine,  Bromine  and  Kali  bichromicum."  Meyhoffer 
considers  that  Iodine  is  most  suitable  for  sporadic  croup 
occurring  in  previously  healthy  subjects,  when  the  disease  is 
more  sthenic  in  form,  and  Ruddock  that  Iodine  should  be 
preferred  to  Bromine  in  scrofulous  patients. 

The  symptoms  indicating  this  remedy  are  not  very  clearly 
marked.  Koch  speaks  in  general  terms  of  the  great  value  of 
Iodine  in  true  croup,  looking  upon  it  as  a  kind  of  panacea, 
but  he  gives  no  special  indications  for  its  use.  Elb  gives 
the  following  excellent  indications  for  this  "  most  efficacious 
and  most  frequently  applicable  remedy": 

"  i.  In  cases  where  there  are  violent  fits  of  coughing, 
threatening  suffocation,  with  whistling  tone  and  great 
anxiety;  hissing,  sawing,  respiratory  sound;  painfulness  of 
the  larynx ;  hoarseness  and  red  face,  synochal  fever ;  conse- 
quently at  the  first  appearance  of  the  disease. 

"2.  In  cases  where  there  are  long  continued  fits  of  loose- 
sounding  coughing,  without  great  danger  of  suffocation, 
which  affords  the  patient  no  relief,  with  slight  painfulness  of 
the    larynx ;  strong   sawing  and    hissing   but    not   whistling 


PSEUDO-MEMBRANOUS    CROUP.  223 

respiratory  sound  ;  temperature  of  the  skin  not  elevated  ; 
with  frequent,  hard,  but  not  full  pulse. 

"  3.  In  cases  where  there  is  want  of  cough,  or  rare,  short, 
loose  sounding,  but  still  genuine  croupy  cough ;  with 
constant,  but  apparently  not  very  troublesome,  oppression 
of  the  chest,  and  rough,  sawing,  not  whistling,  respiratory 
sound  ;  cold,  moist  skin  ;  small,  hard,  quick  pulse. 

"4.  In  cases  where  the  bronchial  ramifications  are  chiefly 
affected,  consequently  where  there  is  want  of  cough,  or  rare, 
short  cough  without  the  croupy  tone ;  inaudible  vesicular 
inspiration  ;  short,  quickened  respiration  ;  loss  of  voice,  with 
weak  sawing,  rather  rattling  respiratory  sound ;  abdom- 
inal inspiration ;  painlessness  of  the  larynx  and  trachea ; 
pale,  fallen-in  countenance  ;  cold  skin,  covered  with  clammy 
sweat,  with  weak,  small,  rapid,  and  even  thready  pulse." 

There  is  roughness  in  the  larynx,  also  painful  pressure  and 
stitching  in  the  same  organ  ;  pressure  in  the  larynx  and 
pharynx,  as  if  swollen  ;  pain  in  the  larynx  with  discharge  of 
hardened  mucus;  constriction  and  heat  in  the  larynx; 
increased  secretion  of  mucus  in  the  trachea;  dry,  short  and 
hacking  cough  ;  soreness  of  the  throat  and  chest  when  in 
bed,  with  wheezing  in  the  throat  and  drawing  pains  in  the 
lungs,  corresponding  with  the  beat  of  the  heart ;  great 
difficulty  in  breathing  ;  tightness  of  the  chest  when  breathing 
deeply;  more  violent  and  quicker  beat  of  the  heart,  with 
smaller  and  more  rapid  pulse  ;  hoarseness,  the  voice  becomes 
deeper,  and  finally  quite  deep  ;  the  face  is  not  bluish  and 
bloated,  but  pale. 

Hartmann  thinks  that  tracheal  and  bronchial  croup  is  the 
proper  sphere  for  Iodine,  especially  when  there  is  a  tendency 
to  torpor,  and  he  says  that  the  Iodine-croup  is  always 
characterized  by  pain  in  the  chest  and  larynx.  I  remember 
hearing  Dr.  Constantine  Hering  make  the  curious  remark, 
that,  while  Bromine  suited  blue-eyed  children,  Iodine  is 
adapted  to  black-eyed  ones,  and  other  observers  have 
confirmed  this.  Hempel  and  Hartmann  are  at  variance  as 
to  the  precise  pathological  state,'  for  Hempel  says  that  it  is 


224  PSE1   I"  l-MEMBRANl  II  S    CROUP. 

the  remedy,  "  especially  in  that  stage  <>f  croup  where  the 
exuded  lymph  begins  to  become  consolidated  as  an  organized 
membrane,  with  suffocative  wheezing  and  a  fully  developed 
croupy  sound  during  the  inspirations,"  while  Hartmann 
affirms  that  "  there  are  no  symptoms  pointing  to  a  pseudo- 
membranous formation  either  in  the  larynx  or  the  upper 
portion  of  the  trachea."  Here  I  consider  that  Ilempel  is 
undoubtedly  correct,  for  in  all  my  cases,  in  which  Iodine 
proved  curative,  false  membranes  were  present.  Baehr  gives 
a  few  needed  words  of  warning  not  to  be  too  ready  to 
change  the  remedy.  "  In  most  cases  Iodium  will  undoubtedly 
have  a  favorable  effect.  Only  we  must  not  indulge  in  the 
expectation  of  cutting  the  disease  short.  A  result  of  this 
kind  only  occurs  in  a  very  small  number  of  cases.  Most 
commonly  the  pathological  process  continues  to  go  on  under 
the  action  of  Iodine,  after  which  it  retrogrades,  as  is  the  case 
in  every  other  inflammation.  What  is  essential  is  that  it 
should  be  kept  confined  within  proper  boundaries.  Even  if 
the  dyspncea  increases  at  first,  this  is  no  reason  why  the  use 
of  Iodine  should  be  discontinued." 

As  to  the  dose,  Hempel  recommends  the  mother-tincture; 
Baehr  the  2nd  decimal  dilution  ;  Elb  the  2nd  to  the  6th 
dilutions  (centesimal,  I  presume)  and  Hartman  the  3rd  or 
4th,  going  up  to  the  12th  ;  I  have  always  used  the  2nd  or 
3rd  decimal.  Whatever  preparation  is  used  care  must  be 
taken  to  have  it  freshly  prepared,  as  a  dilution  even  a  few 
weeks  old  is  not  to  be  depended  on.  Elb's  hint  must  be 
kept  in  mind  ;  by  attending  to  it  I  have  succeeded  where 
success  seemed  beyond  my  reach.  In  all  forms  of  croup  it 
is  of  importance  not  to  intermit  the  medicines  during  sleep, 
for  only  by  their  constant  employment  is  it  possible, 
especially  in  the  bad  cases,  to  stop  the  progress  of  the 
disease."  In  the  year  1858  Dr.  William  Arnold  of  Heidelberg 
introduced  the  use  of  Iodine  inhalations  in  cases  in  which 
that  remedy  was  indicated,  but  failed  to  cure  when  given  in 
the  usual  manner.  "  The  evident  and  visible  effect  of  the 
Iodine-vapors  was  looseness  of  the  cough,  separation  of  the 


PSEUDO-MEMBRANOUS    CROUP.  225 

membrane,  and  consequent  greater  facility  of  respiration. 
The  mode  of  preparation  was  simply  to  pour  a  few  drops  of, 
from  the  strong  tincture  to  the  second  dilution  of  Iodine 
into  a  shallow  vessel  filled  with  boiling  water.  The  child 
was  made  to  inhale  the  vapor  by  holding  its  head  over  the 
vessel,  or  in  its  immediate  neighborhood.  The  preparation  « 
of  the  vapor  was  renewed  more  or  less  often,  as  it  was 
needed,  from  every  two  to  every  six  hours.  At  first  the 
vapor  appeared  to  be  agreeable  to  the  children,  since  they 
endeavored  to  approach  the  steaming  vessel.  Subsequently 
the  effect  seemed  to  be  unpleasant,  for  two  of  the  children 
resisted  the  application  after  the  more  violent  attacks  had 
been  relieved."  Drs.  Hempel,  Drake  and  Schlosser  report 
remarkable  success  from  this  simple  measure. 

To  Dr.  Allomge  belongs  the  credit  of  introducing  Bromine 
as  a  remedy  for  pseudo-membranous  croup,  and  he  asserts 
that  it  is  the  only  remedy  that  can  produce  the  false 
membrane  in  the  larynx  and  trachea  of  the  healthy.  On 
the  other  hand,  Dr.  Meyhoffer,  of  Nice,  thinks  that  Bromine 
is  only  of  use  in  diphtheritic  croup — when  diphtheria  extends 
to  the  air  passages ;  but  it  has  unquestionably  proved 
curative  in  severe  cases  of  pseudo-membranous  croup,  as 
numerous  reported  cases  testify,  though  Hempel  says  that 
it  has  been  used  with  "  variable  and  rather  doubtful  success." 
Hughes  says  that  the  specific  action  of  Bromine  on  croup  is 
unquestionable,  and  a  writer  in  the  British  Journal  of 
HomtvopatJiy,  vol.  V.  thinks  that  "we  must  assign  to  Bromine 
the  first  place  among  the  croup  remedies  we  as  yet  know." 
Baehr  is  in  doubt  as  to  the  place  and  power  of  this  remedy 
in  croup  ;  "  instead  of  Iodine,  many  physicians  recommend 
Bromine  ;  some  successful  cures  with  Bromine  are  reported, 
whereas  others  deny  it  all  power  over  croup.  We  are  not 
yet  able  to  express  a  decided  opinion  on  this  subject,"  and 
again,  "  we  do  not  mean  to  reject  Bromine,  but  it  is  only  in 
mild  cases  that  we  would  substitute  its  use  for  that  of 
Iodine." 

There  is  spasm  of  the  larynx  occasioning  suffocation  ;  cough 


UDO-MEMBR  \NOUS    CROUP. 

with  croup  sound,  hoarse,  wheezing,  fatiguing,  not  permitting 

one  to  utter  a  word.  This  cough  is  generally  without 
expectoration,  while  with  Iodine  the  cough  is  generally  with 

expectoration;  the  respiration  is  wheezing,  alternately  slow 
and  suffocative,  and  hurried  and  artificial.  In  this  remedy 
the  respiration  is  with  dry  sound,  while  with  Iodine  the 
respiration  is  predominantly  with  moist  sound  ;  the  respira- 
tion is  labored,  painful  and  oppressed,  with  gasping  for 
air;  heat  in  the  face;  pulse  rather  hard,  slow  at  first,  and 
afterwards  accelerated.  Ruddock  advises  Bromine  "in 
asthenic  croup  with  extreme  congestion  and  swelling  of  the 
air  passages,  so  that  the  child  breathes  with  great  difficulty, 
throws  his  head  back,  grasps  at  the  throat,  and  evinces 
anxiety.  Affection  of  the  upper  part  of  the  air  tubes;  dry, 
croupy  cough,  like  that  of  a  sheep,  grating  and  tickling,"  and 
Dr.  Guernsey's  indications  for  Bromine  in  croup  and  laryn- 
geal diphtheria  is  "  rattling  of  mucus  in  the  windpipe  when 
coughing,"  which  is  not  very  much  of  a  "keynote,"  after  all. 

The  following  appearances  are  found  in  the  bodies  of 
animals  poisoned  with  Bromine  :  "  Inflammation  of  the 
organs  of  respiration.  A  quantity  of  bloody  foam  in  the 
larynx  and  trachea.  Inflammation  in  the  larynx,  trachea 
and  bronchi  ;  sometimes  consisting  of  slight  reddish  stripes, 
sometimes  of  dark  redness,  sometimes  of  reddish  coloring. 
Great  inflammation  of  the  larynx  and  trachea,  with  exuda- 
tion of  plastic  lymph,  almost  completely  stopping  up  the  air 
passages"  {British  Journal  of  Homoeopathy^  vol.  V). 

This  remedy  has  usually  been  given  in  the  form  of  dilutions 
prepared  with  distilled  water — the  ist  to  the  3d  being  most 
highly  recommended.  The  late  Dr.  E.  II.  Drake,  of  Detroit, 
has  used  inhalations  of  Bromine  in  this  disease  with  eminent 
success.  "  My  manner  of  using  it  is  to  take  a  drachm  vial 
about  half  full  of  pure  water,  put  in  about  four  or  five  drops 
of  Bromine— a  part  only  of  which  will  be  dissolved,  while 
the  residue  will  fall  to  the  bottom,  and  be  taken  up  as  fast 
as  that  already  held  in  solution  passes  off  by  its  exceeding 
volatility.       Thus    the    solution    may    be    kept    of    uniform 


PSEUDO-MEMBRANOUS    CROUP.  227 

strength  for  twenty-four  or  thirty-six  hours.  The  vial  is 
then  held  to  the  mouth  of  the  patient,  so  that  the  medicine 
will  be  inhaled  through  the  mouth,  which  has  seemed  to 
answer  better  than  when  inhaled  through  the  nose.  The 
first  few  inspirations  will  cause  resistance  on  the  part  of 
small  children,  on  account  of  the  unpleasant  sensation  it 
produces  in  the  throat ;  but  by  letting  them  take  two  or 
three,  and  waiting  a  short  time,  a  minute  or  so,  before 
renewing  it,  this  is  easily  overcome.  Most  patients  will  take 
it  while  sleeping.  Care  should  be  taken  to  keep  the  mouth 
of  the  vial  well  closed  with  the  finger  or  cork  when  the 
patient  is  not  inhaling."  Hughes  mentions  that  Dr.  Kafka 
has  contributed  to  the  Allgcmeine  HomoopatJiiscJic  Zeitunglox 
1875,  a  severe  case  of  membranous  croup  in  which  inhala- 
tions of  Bromine  (1st  and  2d  decimal  on  cotton  wool)  had  a 
most  beneficial  effect. 

Kali  bichromicum  is  another  remedy  which  has  been  used 
with  success,  and  Dr.  Hughes  remarks  that  "  there  is  a  large 
accumulation  of  evidence  tending  to  show  that  it  is  a  potent 
remedy  for  true  membranous  croup,"  and  in  a  later  edition 
he  says  that  it  is  "of  all  medicines,  most  homceopathic  to 
membranous  croup — has  frequently  cured  it."  Dr.  Hempel 
thinks  that  it  may  be  used  in  the  last  stage  when  the 
membrane  is  formed,  and  I  have  seen  some  remarkable  cures 
with  this  remedy,  especially  when  the  disease  extended  to 
the  bronchial  tubes.  Dr.  A.  E.  Small,  of  Chicago,  writes  : 
"  I  have  found  this  remedy  of  the  greatest  use  in  arresting 
the  progress  of  membranous  croup  when  the  attack  comes 
on  in  the  morning  with  hoarseness  and  accumulation  of 
mucus  in  the  larynx,  tending  to  pseudo-membranous  forma- 
tion. After  a  few  doses  of  Aconite,  the  3d  decimal,  to  allay 
the  arterial  excitement,  Kali  bichromicum,  the  3d  decimal, 
in  water,  administered  at  short  intervals,  has  produced  a 
speedy  cure." 

The  following  are  the  indications  for  this  remedy  as  given 
many  years  ago  by  the  British  and  Austrian  practitioners. 
The  symptoms  approach  gradually  and  insidiously  ;  at  first, 


228  PSEUDO-MEMBRANOUS    CROUP. 

slight  difficulty  in  breathing  when  the  mouth  is  closed  ;  slight 
elevation  of  temperature;  pulse  irregular  and  intermittent, 
or  frequent  and  small ;  as  the  disease  progresses,  the  difficulty 
of  breathing  increases;  the  sound  of  the  air  as  it  passes 
through  the  trachea  is  shrill,  whistling,  as  if  it  passed  through 
a  metallic  tube  ;  voice  hoarse  ;  cough  not  frequent,  but 
hoarse,  dry,  barking  and  metallic  ;  deglutition  painful;  tonsils 
and  pharynx  red,  swollen  and  covered  with  an  appearance  of 
false  membrane;  after  a  time,  breathing  affected  in  part  by 
the  action  of  the  abdominal  muscles,  and  those  of  the  neck 
and  shoulder-blades ;  head  inclined  backwards;  breath 
offensive  ;  finally,  diminished  temperature  of  the  skin  ;  pros- 
t  rat  ion ;  stupor.  1 1  ughes  says  that  the  thickness  and  tenacity 
of  the  false  membrane  will  always  be  an  indication  for  this 
remedy. 

1  he  English  provers  found  the  following  morbid  appear- 
ances on  the  bodies  of  dogs  poisoned  with  this  drug  •' 
"  Epiglottis  and  rima  glottidis  congested  and  covered  with 
thick,  ropy  mucus  ;  larynx  and  bronchi  filled  with  muco- 
purulent matter.  Mucous  membrane  of  larynx,  trachea  and 
bronchi  deeply  injected.  Larynx,  trachea  and  bronchi  lined 
with  a  false  membrane,  easily  detached.  In  the  bronchi 
polypus-looking  masses  which  could  be  traced  like  cords 
through  all  the  branches  of  the  air  tubes."  {British  fournal 
of  Honuvopatky,  Vol.  V.) 

As  to  the  dose,  Hempel  recommends  a  powder  of  the  3d 
trituration  dry  on  the  tongue  every  two  or  three  hours.  I 
have,  however,  had  the  best  results  from  a  yellow-colored 
solution  of  the  2d  decimal  trituration,  giving  a  teaspoonful 
every  hour  or  half-hour,  and  in  urgent  cases  I  do  not 
hesitate  to  give  the  1st  decimal  trituration,  similarly 
prepared. 

Many  years  ago  I  encountered  a  very  fatal  epidemic  of 
pseudo-membranous  croup,  against  which  our  usual  remedies 
were  not  as  successful  as  one  could  wish,  while  I  noticed 
that  allopathic  treatment  was  worse  than  useless.  In  my 
extremity  I  applied  myself  to  the  study  of  the  homoeopathic 


PSEUDO-MEMBRANOUS    CROUP.  229 

Materia  Medica — that  monument  of  unwearied  industry — 
and  decided  that  Sanguinaria  Canadensis  was  an  appropriate 
remedy,  as  it  presented  the  following  symptoms:  "  ''''Chronic 
dryness  in  the  throat  and  sensation  of  swelling  in  the  larynx, 
and  expectoration  of  thick  mucus.  Aphonia,  with  swelling 
in  the  throat.  ^Continual  severe  cough,  without  expectora- 
tion, with  pain  in  the  head  and  circumscribed  redness  of  the 
cheeks.  Tormenting  cough  with  exhaustion  and  circum- 
scribed redness  of  the  cheeks.  *Croup."  In  the  first 
volume  of  the  Transactions  of  the  American  Institute 
of  HonuvopatJiy  I  found  that  Dr.  Bute,  the  original 
prover,  considered  it  to  be  "  very  effective  in  croup." 
Soon  rffter,  I  was  called  to  an  undoubted  case  of 
pseudo-membranous  croup,  and  as  I  had  no  tincture  of 
Sanguinaria  in  my  office  I  gave  minute  doses  of  Sanguinarin 
in  water,  and  the  result  was  a  rapid  cure.  In  the  course  of 
my  studies  I  read  Professor  Paine's  Epitome  of  Eclectic 
Practice,  in  which  he  gives  the  following  testimony  as  to  the 
efficacy  of  Sanguinaria  in  this  disease  :  "  The  Sanguinaria  is 
one  of  the  most  valuable  remedies  known  in  the  treatment 
of  pseudo-membranous  croup.  It  has  proved  as  much  of  a 
specific  for  that  disease  as  Quinine  has  for  ague.  I  have 
seen  it  used  in  a  great  number  of  cases,  and  have  never 
known  a  single  failure,  It  should  be  made  into  an  acetic 
syrup,  by  adding  twenty  grains  of  Sanguinarin  to  four 
ounces  of  vinegar ;  steep  and  add  one  ounce  of  sugar  to 
form  a  syrup.  Dose,  one  teaspoonful  as  often  as  indicated." 
I  frequently  gave  the  remedy  as  Professor  Paine  directs,  but 
finding  that  the  large  dose  caused  an  unnecessary  aggrava- 
tion, I  reduced  the  quantity,  and  for  a  number  of  years  I 
have  used  the  following  formula  :  dissolve  two  grains  of  the 
1st  decimal  trituration  of  Sanguinarin  in  three  teaspoonfuls 
of  good  vinegar,  adding  six  teaspoonfuls  of  brown  sugar  and 
twelve  of  water,  and  of  this  acetous  syrup  I  give  a  teaspoon- 
ful every  hour  or  every  half  hour.  I  have  given  the 
Sanguinarin  in  the  2d  decimal  trituration,  dry  on  the 
tongue,    but    obtained    better     results    from     the     acetous 


PSEUDO-MEMBRANOUS    CROUP. 

preparation.  <  >f  late  years  1  have  used  the  tincture  a  good 
deal,  especially  since  reading  the  following  ease,  reported 
by  Professor  Helmuth,  of  St.  Louis,  now  of  New  York, 
in    the    fourth    volume    of    the  American  Observer : 

"  We  were  called  to  see  a  child  of  some  ten  years  of  age, 
who  had  been  suffering  from  an  attack  of  whooping  cough, 
and  who  was  taken  with  severe  croup.  The  patient  lived 
about  seven  miles  in  the  country,  and  was  in  a  most  pitiable- 
condition  when  we  arrived.  The  previously-existing 
pertussis  had  much  enfeebled  him,  and  the  croupy  parox- 
ysms were  decidedly  the  worst  which,  in  fifteen  years,  we 
had  seen.  The  suffocative  fits  were  of  the  most  distressing 
character,  and  the  cough  so  severe  that,  as  we  passed  to  the 
house,  the  noise  so  resembled  the  barking  of  a  dog  that  we 
were  certain  that  it  belonged  to  the  canine  rather  than  to 
the  human  species.  There  were  no  other  symptoms  but 
these  :  constant  croupy  cough,  excessive  suffocation, 
hoarseness,  with  tossing  about  the  bed  to  endeavor  to  gain 
air.  He  had  taken  for  some  time  Aconite  and  Spongia, 
which  had  been  administered  by  his  parents,  without  any 
benefit  ;  also  Hepar  sulphur,  with  no  good  result.  Having 
treated  him  before  for  severe  attacks  of  this  kind,  we 
prescribed  Ipecac  and  Kali  bichrom.,  to  *be  taken  every 
fifteen  minutes  in  alternation,  and  being  obliged  to  return  to 
the  city  left  Iodine  and  Tartar  emetic  to  be  taken  if  no  relief 
was  experienced  after  three  hours'  trial  with  the  previous 
medicines.  This  was  about  twelve  o'clock  at  noon.  At 
midnight  we  were  called  again,  and  after  an  hour's  ride  found 
the  little  patient  in  what  we  then  thought  a  dying  condition. 
The  pulse  was  almost  gone,  the  face  livid,  the  breathing 
rattling  and  stertorous,  and  every  symptom  indicating  a 
most  alarming  state  of  suffocation.  The  medicines  had  been 
faithfully  tried,  but  without  result.  While  the  vehicle  was 
being  prepared  for  the  ride,  we  consulted  Dr.  Hale's  New 
Remedies^  and  reading  therein  the  remarks  of  Dr.  Thomas 
Nichol,  and  being  really  at  a  loss  what  to  prescribe,  we  took 
with  us  the  tincture  of  Sanguinaria  Canadensis.    Of  this  were 


PSEUDO-MEMBRANOUS    CROUP.  23I 

mixed  about  twenty-five  drops  in  half  a  glassful  of  water,  and 
a  dessert  spoonful  administered  every  ten  minutes  for  half 
an  hour.  The  symptoms  began  very  gradually  to  abate, 
the  breathing  to  become  less  labored,  and  the  pulse  conse- 
quently to  become  fuller.  The  medicine  was  continued,  at 
longer  intervals,  with  constant  amelioration  of  the  symptoms. 
and  recovery  resulted.  We  are  of  opinion  that  had  it  not 
been  for  the  work  of  Dr.  Hale  this  child  would  have  died  \ 
and  01  passant,  would  advise  our  friends  to  experiment  with 
this  valuable  remedial  agent  in  similar  cases.  We  are  aware 
many  will  say,  "  Where  are  the  symptoms  that  called  for  it  ? 
What  was  the  '  key-note  '  that  demanded  Sanguinaria  ? '' 
There  was  no  key-note  but  the  rattle  of  death.  There  were 
no  symptoms  but  croup  in  its  last  stages — suffocative 
breathing  and  asphyxia. 

Tartar  emetic  is  the  remedy  most  generally  indicated 
when  paralysis  of  the  pneumo-gastric  nerve  threatens,  though 
Baehr  thinks  it  "  is  indicated  if  the  dyspnoea  and  danger  of 
suffocation  are  occasioned  by  movable  patches  of  membrane. 
The  cough  is  indeed  feeble  and  without  resonance,  but  a 
mucous  rale  is  still  distinctly  heard  in  the  trachea."  The 
respiration  is  very  short,  the  dyspnoea  almost  amounts  to 
suffocation,  the  cough  is  loose  and  rattling,  a  shrill,  whistling 
noise  accompanies  both  expiration  and  inspiration,  the  child 
lacks  the  strength  necessary  to  expectorate,  the  chest 
expands  only  on  the  most  desperate  efforts,  and  the  anxiety 
and  prostration  are  very  marked  indeed.  The  face  soon 
becomes  cold  and  bluish,  the  forehead  is  covered  with  a 
profuse  cold  perspiration,  and  the  patient  is  almost  in 
extremis.  "Whilst  Jahr  considers  it  to  be  indicated  when, 
after  the  removal  of  the  dangerous  symptoms,  much  mucous 
secretion  remains,  and  in  the  opposite  circumstances  of  a 
paralyzed  state  of  the  lungs.  Bosch  has  recourse  to  it  when 
the  violence  of  the  attack  is  apparently  broken  up  (transition 
to  the  torpid  croup  ?)  and  others  give  it  only  when  Hepar 
and  Spongia  have  been  ineffectually  employed,  without 
being  able  to  assign  a  distinct  ground  for  its  selection."  (Elb.) 


PSEUDO-MEMBR  ^NOUS    CROl   E>. 

My  own  opinion  is  tint  Tartar  emetic  is  a  remedy  for  severe 
catarrhal  croup,  but  not  for  the  more  dangerous  pseudo- 
membranous form.  Elb  recommends  it  in  the  2d  or  3rd 
dilution,  while  Balir  gives  grain  doses  of  the  2d  trituration 
and  cautions  us  "  not  to  prescribe  this  remedy  in  large  doses, 
for  the  favorable  effect  of  the  act  of  vomiting  is  very 
problematical,  whereas  the  great  depression  caused  by  the 
vomiting  is  sure  to  follow." 

Phosphorus  is  recommended  by  Badir  if  the  cough  has 
lost  all  resonance  and  force,  and  the  mucous  rale  has  ceased  ; 
or  more  especially  if  the  croupous  process  has  invaded  the 
bronchia,  and  the  lungs  have  evidently  become  hyperaemic, 
and  Elb  says  that  it  is  most  likely  to  do  good  when  conges- 
tion of  the  lungs  and  heart  with  blood  is  to  be  regarded  as 
the  cause  of  the  pulmonary  paralysis.  Elb  recommends  the 
2d  or  3d  dilution  ;  Baehr  would  not  dare  give  it  below  the 
third  attenuation. 

We  owe  the  following  indications  for  Bryonia  .to  Elb, 
whose  classical  essay  on  croup  should  be  in  all  hands.  "  The 
indications  for  this  medicine  are  completely  identical  with 
those  of  Phosphorus  for  the  remaining  cough,  only  it  is  to 
be  preferred  in  those  cases  where  the  cough  is  less  deeply 
seated  in  the  trachea  or  fever  is  still  present."  Dr.  Alphonse 
Teste,  many  years  ago,  introduced  Bryonia  in  alternation 
with  Ipecac  as  remedies  for  croup.  "  Ipecac  and  Bryonia 
(but  given  concurrently,  for  both  would  be  inert  alone)  are 
in  all  cases,  whatever  be  the  form  of  the  attack  or  intensity 
of  the  disease,  the  great  modifiers  of  croupal  angina.  These 
medicines  need  not  be  prescribed  at  very  low  dilutions — from 
six  to  twelve  will  suffice.  The  two  solutions  prepared,  they 
should  be  administered  alternately,  a  teaspoonful  every  two 
hours  during  the  period  of  invasion  ;  every  ten  minutes  during 
the  exacerbations,  and  at  intervals  gradually  increased,  when 
those  are  passed."  Jahr  says  that  this  was  done  "  by  the 
advice  of  a  clairvoyant,"  and  the  late  Professor  Williamson, 
of  1'hiladelphia,  once  told  me  that  it  was  a  communication 
from  the  spirit  world.     Here  the  Ipecac  is  prescribed  against 


PSEUDO-MEMBRANOUS    CROUP. 


*SS 


the  spasmodic  element  of  the  disease,  and  the  Bryonia 
against  the  exudative  inflammation,  so  that  this  may  be 
looked  upon  as  a  model  of  alternationist  reasoning  and 
practice.  I  used  this  prescription  in  former  years,  and  found 
it  effective  against  spasmodic  croup,  but  utterly  useless 
against  pseudo-membranous  croup. 

Aphorisms. 

1.  Many  of  the  epidemics  of  croup  during  the  eighteenth 
century,  would  now  be  styled  laryngeal  diphtheria. 

2.  Home  and  Cheyne  remark  that  the  younger  children 
are  when  weaned,  the  more  liable  are  they  to  pseudo-mem- 
branous croup. 

3.  Pseudo-membranous  croup  is  more  prevalent  among 
boys  than  girls,  and  robust,  ruddy,  healthful  children  are 
most  likely  to  be  attacked. 

4.  Season  and  temperature  exercise  a  much  more  powerful 
influence  than  constitution  and  temperament  in  the  causa- 
tion of  this  disease. 

5.  Croup  is  four  times  as  frequent  in  the  Winter  quarter 
as  in  the  Summer  one,,  and  the  mean  monthly  temperature 
and  the  mean  monthly  mortality  from  croup  rise  and  fall 
together  throughout  the  entire  year. 

6.  While  exposure  to  cold  is  the  leading  exciting  cause  of 
pseudo-membranous  croup,  it  must  be  admitted  that  in  very 
many  cases  the  exciting  cause  is  absolutely  inscrutable. 

7.  Second  attacks  of  pseudo-membranous  croup  are  very 
rare. 

8.  A  family  predisposition  to  this  disease  unquestionably 
exits,  but  so  far  it  has  not  been  proved  to  be  hereditary. 

9.  An  obscure  epidemic  influence  is  sometimes  associated 
with  pseudo-membranous  croup,  and  it  is  sometimes,  but 
rarely,  distinctly  endemic,  but  it  is  never  contagious,  though 
diphtheritic  croup  is. 

10.  Croup  holds  a  place  intermediate  between  the  zymotic 
class  of  diseases  and  those  of  the  respiratory  organs. 


:  \\  .  PSEUDO  Ml  MBR  ^NOUS    I  R<  H   I'. 

1 1.  Pseudo-membranous  (.roup  complicates  measles,  small- 
pox, scarlatina,  whooping  cough  and  typhoid  fever,  and  the 
larynx  is  more  or  less  implicate  1  in  the  majority  of  cases  of 
acute  infectious  disease. 

i_\  Croup  is  probably  more  influenced  by  peculiarities  of 
Country  and  climate  than  any  other  disease  of  the  respiratory 
organs. 

[3.  A  cold  and  moist  atmosphere,  with  rapid  alterations 
of  temperature,  together  with  the  vicinity  of  the  sea,  make 
up  the  climate  in  which  croup  is  almost  endemic. 

14.  Hoarseness  in  a  child  is  of  more  moment  than  hoarse- 
ness in  an  adult,  and  roughness  of  the  voice  with  hoarse 
cough  should  always  suggest  croup  to  the  mother. 

15.  In  croup,  the  frequent  cough  is  a  better  omen  than 
the  rare  cough,  and  complete  suppression  of  the  cough  is  one 
of  the  worst  signs. 

16.  As  a  rule,  pseudo-membranous  croup  is  marked  by 
remissions,  which  become  shorter  as  the  disease  advances, 
but  sometimes  it  marches  directly  onward  to  suffocation. 

17.  The  time  for  successful  treatment  is  during  these 
remissions. 

18.  A  sudden  amendment  is  more  likely  to  be  followed  by 
a  relapse  than  a  gradual  one. 

19.  The  leading  homoeopathic  remedies  are  Aconite, 
Iodine,  Bromine,  Kali  bichromicum  and  Sanguinaria ;  minor, 
but  still  important  ones,  are  Tartar  emetic,  Phosphorus  and 
Bryonia. 


CHAPTER    XI. 


Diphtheritic    Croup 


Diphtheritic  croup  is  that  most  serious  variety  of  croup 
which  results  from  the  development  of  the  characteristic 
membrane  of  diphtheria  upon  the  larynx  and  trachea, 
accompanied  by  the  blood-poisoning  which  is  part  and 
parcel  of  the  general  disease.  It  calls  for  a  separate  essay 
on  account  of  its  very  serious  nature,  and  also  because  many 
eminent  writers  and  practitioners  confidently  assert  that 
diphtheritic  croup  and  pseudo-membranous  are  one  and 
the  same  disease — that,  in  fact,  pseudo-membranous  croup 
is  merely  a  sporadic  laryngeal  diphtheria. 

In  all  forms  of  diphtheria,  and,  indeed,  in  every  case  of 
the  disease,  its  appearance  in  the  larynx  is  to  be  dreaded 
beyond  any  other  complication.  The  general  opinion  is  that 
the  diphtheritic  membrane  reaches  the  larynx  by  direct 
extension  from  the  fauces,  but  Dr.  Wade  of  Birmingham, 
England,  asserts  that  he  has  never  found  the  laryngeal 
exudation  continuous  with  the  pharyngeal.  Dr.  Ludlum  of 
Chicago  holds  the  opposite  view  :  "  The  exudation  may 
commence  in  the  larynx  or  trachea,  but  is-more  prone  to 
follow  upon  that  which  takes  place  in  the  fauces.  Sometimes 
the  curtain  which  envelopes  the  latter  extends  through  the 
glottis  into  the  vocal  organ,  and  encroaches  upon  the  trachea, 
even  down  to  its  bifurcation.  Such  a  case  would  be 
accompanied  by  extreme  dyspnoea."  Oertel  of  Munich 
points  out  that  "  there  are  cases  on  record  in  which  diphtheria 
localized  itself  first  in  the  mouth,  on  the  lips,  and  from 
these  points,  skipping  the  fauces  entirely,  at  once  attacked 
the  larynx.     Finally,    there    are    rarer    ones,    in    which    the 


DIPH  rHERITIC    CR(  'I   P. 

diphthera  involved  the  larynx  first,  and  the  mucous 
membrane  of  the  fauces  secondarily,  while  it  also  i  xtem 
downwards  into  the  trachea  or  bronchi."  My  own  personal 
experience  is.  that  as  a  very  general  rule,  the  disease 
originates  by  extension  from  the  fauces,  and  that  it  isa  very 
rare  thing  to  find  it  originate  in  the  larynx.  1  remember 
one  notable  case  in  which,  when  I  first  saw  the  patient,  the 
Only  diphtheritic  membrane  to  be  found  covered  both  eyes 
like  two  patches  of  very  thick  cream  ;  no  membrane  in  the 
fauces  and  no  laryngeal  symptoms  whatever.  In  twenty- 
four  hours  the  larynx  became  inflamed,  abundant  diphtheritic 
membranes  were  thrown  out,  and  the  patient  died  forty- 
eight  hours  after  the  first  appearance  of  the  laryngeal 
symptoms.  At  death,  no  diphtheritic  membrane  was  to  be 
found  in  the  fauces. 

The  larynx  is  likely  to  be  affected  when  the  diphtheritic 
membrane  covers  the  fauces  very  completely,  extending  very 
far  down  into  the  pharynx,  though  I  have  seen  a  number  of 
cases  in  which  large  patches  of  diphtheritic  membrane 
covered  both  tonsils,  the  mucous  membrane  of  the  pharynx 
being  almost  normal,  when  suddenly  the  dreaded  laryngeal 
symptoms  appeared,  and  that,  too,  at  a  very  early  period  of 
the  disease.  This  was  possibly  caused  by  multiple  infection, 
but  more  likely  by  breathing  the  poison  contained  in  the 
mouth  and  fauces — a  true  secondary  infection. 

Physicians  well  read  in  historical  medicine  know  that 
diphtheria  is  not,  by  any  means,  a  new  disease,  but  an  old 
disease  which  manifests  itself  only  at  somewhat  long 
intervals,  and  also  that  all  writers  on  diphtheria  make 
mention  of  diphtheritic  croup.  Aretaeus,  the  Cappadocian, 
styled  by  Squire  "the  founder  both  of  our  knowledge  and 
treatment  of  diphtheria,"  mentions  that  the  disease,  styled 
by  him  Egyptian  and  Syrian  Ulcer,  sometimes  extended 
from  the  fauces  to  the  windpipe,  where  it  proved  rapidly 
fatal  by  suffocation,  and  he  adds  that  children  under  puberty 
are  especially  subject  to  the  laryngeal  complication.  The 
Spanish  physicians   Merrera,  Villa   Real  and  Fontecha,  who 


DIPHTHERITIC    CROUP.  237 

wrote  in  the  beginning  of  the  seventeenth  century,  give  in 
their  works  most  excellent  descriptions  of  the  disease  which 
we  call  diphtheria,  styled  by  them  garrotilla  or  morbus 
sit ffocaus.  on  account  of  the  laryngeal  complication.  Alay- 
mus,  who  describes  the  diphtheria  epidemics  of  Sicily  in  the 
earl)r  part  of  the  seventeenth  century,  speaks  of  the  disease 
as  extending  to  the  larynx,  and  also  of  its  commencement 
there.  In  the  year  1753,  Dr.  Cadwallader  Golden,  of  New 
York,  observed  a  disease  which  could  only  be  diphtheria. 
"  It  is  attended  with  a  moist,  putrid  heat,  the  skin  being 
seldom  parched.  The  pulse  is  usually  low,  but  frequent  and 
irregular.  The  countenance  dejected,  with  lowness  of  spirits ; 
no  considerable  thirst ;  the  tongue  much  furred,  and  the 
furring  sometimes  extends  over  the  tonsils  as  far  as  the  eye 
can  reach.  At  other  times,  in  the  mildest  kind,  the  tonsils 
appear  only  swelled,  with  white  specks  of  about  a  quarter 
of  an  inch  or  half  an  inch  in  diameter,  which  are  thrown  off 
from  time  to  time  in  tough  cream-colored  sloughs.  Some- 
times all  the  parts  near  the  gullet  or  throat  are  much  swelled, 
both  inwardly  and  outwardly,  so  as  to  endanger  suffocation, 
and  frequently  mortify;  but  most  generally  the  swelling 
internally  is  not  so  much  as  to  make'  swallowing  difficult. 
Sometimes  those  swellings  imposthumate.  The  last  com- 
plaint is  commonly  of  an  oppression  or  strictness  in  the 
upper  part  of  the  chest,  with  difficulty  of  breathing,  and  a 
deep,  hoarse,  hollow  cough,  ending  in  a  livid,  strangled-like 
countenance,  which  was  soon  followed  by  death."  From  the 
last  sentence  we  are  led  to  conclude  that  croup,  undoubtedly 
diphtheritic  in  its  nature,  was  the  usual  termination  of  the 
disease,  and  the  same  peculiarity  has  been  observed  in  other 
epidemics. 

In  the  year  1755,  Dr.  Richard  Russell,  of  London,  noted 
croup  in  connection  with  an  epidemic  of  malignant  angina, 
and  there  can  be  little  doubt  but  that  in  our  day  that  this 
malignant  angina  would  be  styled  diphtheria,  and  that  the 
accompanying  croup  was  diphtheritic  in  its  nature.  Ten 
years  later  Francis  Home  wrote  his  classic  work  in  which  he 


238  IMl'll  I  HER]  ll'      CR<  »UP. 

describcswh.it  we  now  style  pseudo-membranous  croup,  and 
he  was  very  careful  to  draw  the  diagnostic  lines  between  it 
and  diphtheritic  croup,  which  he  had  certainly  seen.  In 
1779,  Dr.  Johnstone,  of  Kidderminster,  insisted  on  the  essen- 
tial difference  between  the  two  diseases,  but,  in  the  words  of 
Dr.  Squire,  "  Unfortunately,  though  argued  with  learning 
and  experience,  these  views  did  not  prevail ;  the  name  of 
croup  was  applied  to  the  epidemic  complication,  and  the 
treatment  laid  down  by  Home  for  the  one  disease  was  very 
energetically  employed  against  the  other."  The  epidemics 
of  croup  at  Cremona  and  Liskeard,  referred  to  in  the  chapter 
on  pseudo-membranous  croup,  appear  to  have  been  closely 
akin  to  the  disease  described  by  Dr.  Richard  Russell,  and 
the  latter  half  of  the  eighteenth  century  and  the  first  years 
of  the  nineteenth  are  notable  for  numerous  outbreaks  of 
malignant  angina  associated  with  laryngeal  inflammation. 
The  "Suffocative  Angina,"  so  well  described  by  Dr.  Samuel 
Bard,  of  New  York,  in  1771,  appears  to  have  been  identical 
with  diphtheria,  and  he  remarks  that  he  saw  upon  several 
children  in  the  same  family  thick,  coriaceous  pellicles  formed 
upon  the  tonsils,  and  propagated  from  the  pharynx  to  the 
trachea.  "  Three  post-mortem  examinations  exhibited  to 
him,  as  a  uniform  result,  white,  thick,  coriaceous,  elastic 
layers  of  concrete  matter,  which  lined  the  walls  of  the 
pharynx.  A  membraniform  tube  of  the  same  nature 
advanced  into  the  trachea  and  became  progressively  thinner 
in  proportion  as  it  descended  into  the  bronchi.  The  tracheal 
mucous  membrane  was  slightly  inflamed ;  that  of  the 
pharynx,  after  the  pellicles  were  removed,  was  found  rather 
pale."  Dr.  Squire  claims  that  the  disease  seen  by  Dr.  Bard 
was  diphtheria,  and  certainly  the  description  of  the  laryngeal 
complication  exactly  tallies  with  diphtheritic  croup,  while  it 
is  quite  unlike  the  morbid  state  which  we  call  pseudo-mem- 
b/anous  croup.  To  quote  Dr.  Squire:  "  Epidemic  croup  is 
strictly  diphtheria  ;  when  that  disease  prevailed  epidemically 
in  England  at  the  end  of  the  last  century,  any  fresh  outbreak 
was  so  spoken  of;  an  outbreak  at  Chesham,  in  Buckingham- 


DIPHTHERITIC    CROUP.  239 

shire,  in  1793,  carefully  described  by  Mr.  Rumsey,  leaves  no 
doubt  upon  this  point;  sometimes  on  its  appearance  in  a 
fresh  locality  it  was  simply  called  croup,  and  the  word 
excited  as  much  terror  then  as  diphtheria  has  again  given 
us  reason  to  associate  with  the  disease  it  now  designates." 

Many  of  the  essays  presented  to  the  great  Parisian 
concours  on  croup  (1807)  really  describe  diphtheritic  croup, 
and  confusion  reigned  till  in  181 8  the  illustrious  Bretonneau 
investigated  the  epidemic  of  diphtheria  at  Tours.  The 
conclusions  at  which  he  arrived  have  influenced  the  views  of 
French  physicians  down  to  the  present  day,  and,  as  is  well 
known,  the  vast  majority  of  them  agree  in  considering  that 
diphtheria  and  true  croup  are  one  disease,  the  latter  being  a 
mere  local  manifestation  of  the  former.  A  goodly  number  of 
practitioners,  among  them  Bricheteau,  Emangard  and  Des- 
ruelles,  opposed  these  views,  and  the  original  work  of  Dr. 
Bland,  of  Beaucaire,  entitled  Nouvelles  Recherches  sur  la 
Laryngo-Tracheite  is  even  to-day  one  of  our  best  authorities 
on  the  subject.  In  1820,  Dr.  Mackenzie,  of  Glasgow, 
described  a  disease  strikingly  similar  to  that  seen  by  Breton- 
neau, and  from  that  date  the  two  diseases  were  described 
separately.  In  1826,  Dr.  Abercrombie  described  a  fatal 
throat  affection  extending  to  the  windpipe,  which  was  very 
fatal  among  the  children  in  Edinburgh,  and  he  adds  that  "it 
is  evidently  quite  distinct  from  the  idiopathic  inflammation 
of  the  mucous  membrane  of  the  larynx  to  which  we  com- 
monly apply  the  name  of  croup."  During  the  succeeding 
decades,  a  malignant  angina,  unquestionably  diphtheritic  in 
in  its  nature,  often  accompanied  by  a  laryngeal  complication, 
raged  at  intervals  in  the  three  Kingdoms,  and  the  laryngeal 
complication  was  always  carefully  distinguished  from  true 
croup. 

In  1 858,.  the  great  epidemic  of  diphtheria  invaded  England, 
and  though  diphtheritic  croup  was  at  first  considered  to  be  a 
distinct  affection  from  pseudo-membranous  croup,  Dr.  Prosser 
James,  in  the  first  edition  of  work,  Sore  Throat,  its  Nature, 
Varieties  and  Treatment,  contended  that  "  both  are  alike  the 


240  DIPH  rHERl  II*      CR'  ■ 

manifestation  of  an  inflammatory  condition  tending  to 
exudation" — exudation  being,  in  fact,  regarded  as  the  grand 
characteristic  of  the  disease.  Dr.  R.  II.  Semple,  who  had 
probably  been  inoculated  with  the  French  views  while  trans- 
lating Bretonneau's  Memoirs  for  the'lVew  Sydenham  Society, 
had  long  held  that  the  two  diseases  are  really  one,  and 
towards  the  close  of  the  epidemic  (1868)  Dr.  Thomas  Hillier, 
a  distinguished  writer  on  the  diseases  of  children,  declared 
that  he  could  detect  no  difference  between  membranous 
croup  and  laryngeal  diphtheria.  A  few  years  later  Dr. 
George  Johnston  and  Dr.  Morell  Mackenzie,  the  greatest 
authority  on  throat  diseases  in  Great  Britain,  gave  in  their 
adhesion  to  the  new  doctrine,  and  in  1870,  Sir  William 
Jenner,  who  had  long  held  that  the  two  diseases  were 
distinct  entities,  finally  pronounced  himself  "  inclined  to 
think  that  the  two  diseases  are  really  identical."  Sir  William 
enunciated  his  new  views  with  great  force  and  eloquence  at 
a  debate  on  the  subject  at  a  meeting  of  the  Royal  Medico- 
Chirurgical  Society.  The  discussion  originated  in  the  report 
of  a  committee  recommending  that  the  word  "  croup  be 
henceforth  used  wholly  as  a  clinical  definition,  implying 
laryngeal  obstruction,  occurring  with  febrile  symptoms  in 
children  " — a  doctrine  which,  if  acted  upon,  would  turn  the 
pathology  of  the  subject  backward  two  centuries. 

In  the  United  States  the  greatest  names  in  pathology — 
George  B.  Wood,  Austin  Flint,  J.  Lewis  Smith',  Fordyce 
Barker,Henry  Hartshorne  and  others — hold  that  true  croup — 
pseudo-membranous  croup — is  a  wholly  distinct  disease  from 
laryngeal  diphtheria,  and  I  can  only  recall  two  names  of 
note,  J.  F.  Meigs  and  A.  Jacobi,  who  hold  the  contrary  view. 
Dr.  Jacobi  attributes  this  result  to  the  influence  of  the 
writings  of  Vogel  and  von  Niemeyer  upon  the  American 
medical  mind,  and  certain  it  is  that  the  views  of  Meigs  and 
Jacobi  are  held  by  but  a  small  majority  of  the  medical  men 
of  this  continent. 

In  Germany,  many  eminent  pathologists,  among  them 
von    Niemeyer,   Oppolzer,    Letzcrich,   Vogel,   with    Rudolph 


DIPHTHERITIC    CROUP.  24 1 

Virchow,  the  most  eminent  of  them  all,  deny  the  unity  of 
diphtheria  and  pseudo-membranous  croup.  Steiner  talks  on 
both  sides  of  the  question,  stating  that  "  the  attempt  to 
distinguish  croup  and  diphtheria  as  two  entirely  distinct 
diseases  has  been  unsuccessful,  both  from  an  anatomical  and 
from  a  clinical  standpoint."  Yet  he  concedes  that  "in 
diphtheria  the  lesion  is  similar  to  that  of  croup,  only  with 
this  difference,  that  in  croup  the  exudation  takes  place  upon 
the  free  surface  of  the  mucous  membrane,  while  in  diphtheria 
it  occurs  at  the  within  the  tissue,  and  thus  produces  necrosis 
and  loss  of  substance  of  the  mucous  membrane."  This  is 
an  important  distinction  from  the  anatomical  standpoint, 
and  he  finally  admits  that  while  "  true  croup  is  not  a  conta- 
gious disease,"  "  diphtheritic  croup  possesses  this  quality  in 
a  marked  degree,"  which  is  certainly  of  great  moment  from 
a  clinical  standpoint. 

In  some  epidemics  the  appearance  of  the  diphtheritic 
membrane  on  the  larynx  and  trachea  is  of  common  occur- 
rence, while  in  other  epidemics  it  is  very  rare.  Why  it  is  so 
we  cannot  tell,  but  though  unexplained,  still  the  fact  remains 
a  fact.  In  low,  swampy  land,  and  on  the  banks  of  lakes  and 
ponds,  laryngeal  diphtheria  is  far  more  common  than  on 
high,  rolling  land.  While  practicing  in  Simcoe,  Province  of 
Ontario,  I  found  that  diphtheritic  croup  was  more  apt  to 
appear  near  Lake  Erie  than  at  a  distance  from  it,  and  that 
a  river  or  creek  had  not  the  same  deleterious  effect  as  bodies 
of  standing  water.  So  common  was  laryngeal  diphtheria  in 
some  of  the  Spanish  epidemics  of  the  seventeenth  century, 
that  the  entire  morbid  state  was  styled  morbus  strangulato- 
rius  or  garrotilla.  It  was  very  common  in  the  famous 
epidemic  of  Tours,  so  well  described  by  Bretonneau.  "  In 
comparing  together  the  morbid  lesions  observed  in  fifty-five 
subjects  of  all  ages,  who,  in  the  course  of  two  years  had 
fallen  victims  to  epidemic  angina,  I  find  that  it  once 
happened  that  the  false  membrane  existed  in  the  trachea 
without  any  exudations  being  found  either  upon  the  tonsils 
or  upon  any  other  part  of  the  pharynx.    Six  or  seven  times, 


242  DIP11  1  iiri:i  1  [(     CR<  >UP. 

that  is  to  say,  in  the  proportion  of  one  to  nine,  the  membran- 
iform  exudation  reached  to  the  extreme  ramifications  of  the 
bronchi.  In  a  third  of  the  whole  number  it  passed  beyond 
the  great  division  :  in  all  the  rest  it  terminated  at  different 
distances  from  the  trachea,  so  that  the  mechanical  obstacle 
offered  to  respiration  by  the  development  of  the  false 
membrane  always  appeared  to  be  the  immediate  cause  of 
death.  A  single  exception  was  observed.  A  child  who 
ared  to  die  of  exhaustion,  on  the  fifteenth  day,  from 
malignant  angina,  without  any  other  symptoms  than  a 
continuous  vomiting,  had  the  pharynx  lined  with  thick 
pellicle,  which  did  not  pass  beyond  either  the  commence- 
ment of  the  oesophagus  or  the  entrance  of  the  glottis" 
{Bretonneaus  First  Memoirs,  1821).  Mr.  Thompson,  of 
Launceston,  England,  says  that  of  485  cases  which  came 
uihU  r  his  observation,  the  air  passages  were  involved  in  only 
fifteen,  eleven  of  them  dying  within  a  few  hours  of  the 
commencement  of  the  croupous  breathing'.  Mr.  Schofield, 
of  Highgate,  near  Birmingham,  had  thirteen  fatal  cases  of 
diphtheria  in  his  practice,  in  three  of  which  it  assumed  the 
form  of  croup.  Dr.  J.  F.  Meigs,  of  Philadelphia,  lost  six 
patients  with  diphtheria,  and  "in  all  but  one  the  fatal 
termination  was  caused  by  the  extension  of  the  exudation 
t  1  the  larynx."  Dr.  Capron,  of  Guilford.  England,  had  nine 
fatal  cases  of  diphtheria,  three  of  them  dying  croupous.  Dr. 
Heslop,  of  Birmingham,  England,  thinks  that  the  disease 
attacked  the  larynx  in  about  five  per  cent,  of  the  cases  he 
had  seen  in  that  city.  Of  26  fatal  cases  of  diphtheria 
reported  by  correspondents  of  the  British  Medical  Journal 
(1859)  nine,  including  one  from  bronchitis,  died  from  the 
laryngeal  complication.  Dr.  Squire  remarks  that  two-thirds 
of  his  cases  of  diphtheria  suffered  from  laryngeal  complica- 
tions, and  that  the  mortality  was  very  high,  about  80  per 
cent,  of  the  croupous  cases.  This  closely  corresponds  with 
the  statistics  of  M.  Roger,  for  the  Children's  Hospital  in 
Paris,  in  [859  and  [860,  which  show  a  mortality  of  about  JJ 
per  cent,  in    laryngeal  diphtheria.     Dr,  Crichton,  of   Edin- 


DIPHTHERITIC    CROUP.  243 

burgh,  gives  the  results  of  45  cases  of  diphtheria  observed 
in  his  practice.  Of  these,  25  were  males  and  20  females; 
nine  proved  fatal,  or  20  per  cent.  Six  of  the  deaths  were 
from  extension  of  the  diphtheria  to  the  larynx,  and  the 
remaining  three  died  of  asthenia.  The  average  age  of  the 
fatal  cases  was  seven  years.  Dr.  Hillier  says  that  "  of  the 
cases  of  diphtheria  that  have  occurred  in  the  Children's 
Hospital  (London)  two-thirds  of  the  cases  have  suffered 
from  laryngeal  complications."  Meigs  and  Pepper  remark 
that  "  the  frequency  of  its  occurrence  varies  much  in  different 
epidemics,  the  proportion  varying  from  one  or  two  per  cent, 
to  as  high  as  fifty  per  cent,  of  all  the  cases."  Oertel  thinks 
that  "  the  younger  the  patient  the  greater  is  the  danger  that 
even  the  lighter  forms  of  the  disease  may  involve  the  larynx, 
while  the  more  extensive  inflammations  take  this  dangerous 
course  almost  invariably."  Jacobi,  whose  immense  experi- 
ence entitles  him  to  the  most  respectful  consideration,  says, 
"  I  do  not  know  that  sex  exerts  any  predisposing  influence 
over  diphtheria,  yet  of  the  600  cases  or  thereabouts  of 
laryngeal  diphtheria  in  which  I  either  personally  performed 
tracheotomy,  or  observed  the  progress  of  the  disease  in  the 
practice  of  others,  I  found  the  majority  in  males,  and  the 
recoveries  in  inverse  proportion  to  the  number  thereof;  the 
mortality  being  greater  among  boys."  The  writer  has  seen 
over  eighteen  (18)  hundred  cases  of  true  diphtheria,  besides 
many  hundreds  of  cases  of  pseudo-diphtheria — a  form  of 
morbid  action  which  may  be  said  to.  bear  the  same  relation 
to  true  diphtheria  that  cholera-morbus  does  to  Asiatic 
cholera — and  the  result  of  his  observation  is,  that  laryngeal 
symptoms  have  appeared  in  eighteen  per  cent,  of  all  the 
cases  of  true  diphtheria  seen  from  1858  to  1870,  and  only 
three  per  cent,  in  all  cases  of  true  diphtheria  seen  from  1871 
to  1884.  I  have  never  observed  laryngeal  complications  in 
all  the  cases  of  pseudo-diphtheria.  Of  those  attacked  with 
diphtheritic  croup,  a  very  large  proportion  died — not  less 
than  seventy  per  cent. — and  the  fatality  was  largely  influ- 
enced by  the  locality. 


-44  i  >  I  ii  r  r  HER]  i  [(     CRi  »Ur. 

Diphtheritic  croup,  then,  appears  in  two  forms,  as  an 
idiopathic  affection  and  as  an  extension  of  the  disease  from 
the  lances;  the  first  form  is  quite  rare,  the  second  is  the 
most  common  phase  of  the  malady.  When  it  appears  as  an 
idiopathic  disease  the  local  symptoms  are  commonly  preceded 
for  some  days  by  slight  fever,  which  is,  in  the  early  stage, 
much  less  severe  than  in  the  case  of  pseudo-membranous 
croup;  and  from  the  very  faintest  inception  of  the  morbid 
process,  an  amount  of  depression  is  present  which  is  out  of 
all  proportion  to  the  local  symptoms,  for  the  very  source  of 
life  is  already  being  prostrated  by  what  some  English  writers 
oddly  term  a  "morbid  poison."  It  must  be  noted  that  as 
soon  as  the  exudative  inflammation  attacks  the  larynx,  the 
fever  rises  at  once,  and,  curiously  enough,  the  feeling  of 
prostration  seems  to  pass  away-  to  a  considerable  extent. 
Jacobi  accurately  remarks  that  "  fever  and  pain  are  not 
necessarily  prominent  symptoms,"  and  in  some  of  my  worst 
cases  the  patients  had  hardly  any  fever  and  made  no 
complaint  of  pain.  Soon  a  slight  cough,  not  at  all  hoarse, 
comes  on,  and  this  is  preceded  for  as  much  as  twenty-four 
hours  by  a  slight  trilling  sound  in  the  larynx,  only  to  be 
detected  by  ausculation,  which  should  constantly  be  used  in 
all  cases  of  diphtheria.  But  this  slight  and  apparently 
trifling  cough  speedily  assumes  the  loud,  clangorous  character 
of  a  true  croupous  cough,  and,  at  the  same  time,  the  respira- 
tion becomes  stridulous.  The  cough,  which  evidently  causes 
great  suffering  to  the  child,  has,  in  the  graphic  words  of 
Oertel,  "a  peculiar,  barking,  flat  sound  without  resonance," 
which  an  experienced  ear  can  readily  differentiate  from  the 
cough  of  pseudo-membranous  croup.  The  roughness  and 
hoarseness  of  the  voice  increases  with  alarming  rapidity,  and 
soon  complete  aphonia  sets  in,  though  the  mere  act  of 
speaking  seems  to  cause  no  pain.  Inspiration  is  very  slow, 
long-drawn  and  whistling,  while  expiration  is  short  and 
superficial.  Suddenly,  a  [rightful  paroxysm  of  dyspnu-a  sets 
in,  apparently  caused  by  spasm  of  the  laryngeal  muscles. 
Suffocation   now   appears  to  be  imminent ;  the  child  cannot 


DIPHTHERITIC    CROUP. 

lie  down  ;  the  pale,  bluish  skin  is  covered  with  perspiration, 
and  all  the  powers  of  life  fail  rapidly.  I  have  known  death 
occur  during  one  of  these  paroxysms,  and  this  is  apt  to  be 
the  case  when  a  feeble  child  has  been  thoroughly  saturated 
with  the  diphtheritic  poison.  As  a  general  thing,  however, 
the  paroxysm  passes  away  and  is  replaced  by  an  interval  of 
comparative  ease  and  restfulness,  but  soon  another  paroxysm 
comes  on  with  still  more  alarming  phenomena,  leaving  the 
child  still  more  exhausted.  The  intervals  between  the 
paroxysms  become  more  and  more  brief  till  the  child 
becomes  comatose  and  passes  quietly  away. 

Another  group  of  cases  presents  very  similar  symptoms, 
but  without  the  distressing  paroxysms  of  suffocation.  In 
these  the  pseudo-membrane  forms  and  thickens,  the  cough 
becomes  more  frequent  and  more  severe,  and  the  disease  is 
quite  similar  to  true  croup,  but  with  less  febrile 
reaction,  and  with  the  peculiar  cough  already 
described.  As  the  larynx  becomes  more  and  more 
blocked  up  with  the  diphtheritic  membrane,  the  respiration 
is  quickened  and  the  dyspnoea  finally  becomes  extreme  ;  the 
inspiration  is  whistling  and  very  much  protracted;  the  face 
is  pale  and  anxious ;  the  sufferer  vainly  seeks  for  relief  from 
change  of  posture,  and  finally  death  ensues,  though,  as  Dr. 
Charles  West  accurately  remarks,  "without  being  ushered  in 
by  that  urgent  dyspnoea  and  those  violent  efforts  to  obtain 
air  which  attend  most  cases  of  cynanche  trachealis."  The 
cough  is  weaker  and  less  frequent  as  death  approaches. 
'  In  the  second  class  of  cases  the  patients  are  attacked  with 
diphtheritic  croup  in  the  course  of  the  ordinary  pharyngeal 
diphtheria.  It  may  either  come  on  suddenly,  or  the  exten- 
sion may  be  marked  by  a  little  huskiness  and  weakness  of 
the  voice,  while  the  breathing  is  irregular  and  imperfect. 
Soon  the  well-known  cough  comes  on  with  extreme  dyspnoea, 
sopor  supervenes,  and  death  closes  the  scene  often  within  a 
few  hours  of  the  laryngeal  attack.  Dr.  J.  Lewis  Smith  says 
that  "  occasionally,  by  great  effort  on  the  part  of  the  child 
or  by  fortunate  treatment,  a  portion  of  the  pseudo-membrane 


j.|"  DIPHTHERITK      CR01   P. 

is  expectorated,  and  for  some  hours  there  is  apparently  great 
improvement,  but  it  is  only  in  exceptional   crises   that  the 

plastic  formation  is  not  speedily  and  fully  reproduced." 

In  patients  in  whom  the  disease  has  extended  from  the 
fauces  to  the  larynx,  the  glands  of  the  neck  and  throat  swell, 
the  tongue  gets  very  red,  especially  at  the  tip,  and  a  thick, 
yellowish  fur  of  foul  smell  covers  the  entire  organ.  The 
breath  is  extremely  offensive,  and  a  thin  and  fetid  fluid  runs 
from  the  nose  and  eyes,  and,  if  the  patient  lives  long  enough, 
false  membranes  form  on  both  nose  and  eyes.  The  urine  is 
scanty  and  high-colored,  and  albuminuria  appears  about  the 
fifth  or  sixth  day.  At  times  the  urine  is  wholly  suppressed, 
and  I  have  never  known  these  cases  to  recover.  Oertel  and 
Henoch  think  that  diphtheria  of  the  trachea  rarely  occurs 
without  the  co-existence  of  diphtheria  in  the  fauces,  but  I 
have  repeatedly  remarked  it,  but  not  of  late  years. 

In  patients  in  whom  the  disease  is  primarily  developed  in 
the  larynx,  precisely  the  same  group  of  symptoms  makes  its 
appearance,  but  not  so  virulent,  unless,  indeed,  the  patient 
should  live  a  week  or  longer  after  the  appearance  of  the 
laryngeal  diphtheria. 

When  a  favorable  termination  is  about  to  take  place, 
improvement  may  be  looked  for  about  the  third  or  fourth 
day.  One  of  the  earliest  of  the  favorable  signs  is  the 
increased  facility  of  swallowing,  and  this  may  take  place 
even  when  the  pharynx  and  its  diphtheritic  membrane  is 
apparently  unchanged.  Next,  membranous  shreds  are  expec- 
torated, or  still  more  frequently  they  are  swallowed.  Some- 
times such  a  mass  of  them  passes  into  the  intestinal  canal 
that  the  patient  is  made  quite  sick,  and  this  is  one  of  the 
very  few  instances  in  which  the  homceopathic  physician  is 
justified  in  administering  a  laxative.  On  examining  the 
stools,  large  quantities  of  the  characteristic  membrane  are 
found,  and  the  patient  soon  brightens  up  on  being  relieved 
of  the  offending  substance.  Tolle  causam.  The  fever 
decreases,  and  is  succeeded  by  long-continued  sweats ;  the 
alarming  laryngeal  symptoms  decline,  though  hoarseness  the 


DIPHTHERITK      CROUP.  247 

result  of  a  partial  paralysis  of  the  vocal  cords  together  with 
weakness  of  the  laryngeal  muscles,  lasts  for  quite  a  time 
after  restoration  to  health  ;  nosebleed  comes  on  without  any 
assignable  cause ;  and  the  quantity  of  urine  is  greatly 
increased,  while,  at  the  same  time,  the  albumen  finally 
disappears. 

During  the  process  of  cure,  important  changes  take  place 
in  the  diphtheritic  membrane  itself.  We  see  these  changes 
in  the  pharynx,  and  we  infer  that  similar  changes  take  place 
in  the  laryngeal  membrane.  Dr.  D.  Francis  Condie  gives 
the  following  excellent  account  of  these  changes:  "In 
favorable  cases,  as  the  membranous  exudation  becomes 
detached  its  place  is  quickly  supplied  by  a  new  formation, 
and  after  each  separation  it  becomes,  in  general,  white,  and 
much  thinner.  In  other  cases,  the  exudation,  instead  of 
being  separated  in  fragments,  becomes,  in  part,  softened  to 
a  pulpy  consistence,  and  is  discharged  from  the  mouth  mixed 
with  bloody  mucus.  This  separation  and  renewal  of  the 
pseudo-membranous  deposit  continue,  in  most  cases,  for  the 
space  of  eight  or  ten  days.  When,  finally,  it  ceases  to 
appear,  it  leaves,  most  generally,  the  mucous  membrane  to 
which  it  has  been  attached  perfectly  sound  throughout  its 
whole  extent ;  of  a  light-red,  uniform  color,  and  covered, 
usually,  with  a  thick,  yellow  mucus,  more  or  less  resembling 
pus.  At  the  same  time  the  aspect  of  the  child  is  greatly 
improved.  The  features  brighten  and  lose  the  dull  and 
haggard  look  which  characterizes  all  serious  diphtheria  ;  the 
tongue  becomes  moist  and  clean  ;  the  skin  warmer,  moister 
and  more  natural,  and  slowly,  very  slowly,  the  patient 
regains  his  former  health  and  strength." 

On  the  other  hand,  should  the  case  be  about  to  terminate 
unfavorably,  the  disease  marches  on  with  steady  and  rapid 
strides  ;  the  respiration  becomes  more  and  more  stertorous  ; 
the  cough  becomes  weaker,  and  finally  is  entirely  suppressed; 
the  face  becomes  livid  and-ghastly  ;  the  skin  cool  and  of  a 
dull,  dusky,  purple  hue  ;  the  child  sinks  into  a  partially 
comatose  state,  and  death  often  takes  place,  as  Dr.  Ludlam 
remarks,  "  without  a  sigh  or  a  groan." 


248 


hi 


TIC    CI 


Dr.   Thomas  Hillier  remarks  that  "  the  laryngeal symptdms 

set   in   on   tin  nd  or  third  'day  ;  in   a  very  large 

proportion  of  cases  within  the  first  week,"  and  he  adds  that 
he  has  "  seen  them  occur  once  on  the  twelfth  and  once  on 
the  nineteenth  day  of  the  disease."  Dr.  J.  F.  Meigs  says  : 
"  If  it  extend  into  the  air  passages  very  soon  after  the 
invasion,  it  may  cause  death  within  a  few  days.  In  most  of 
the  cases,  however,  the  larynx  does  not  become  implicated 
under  live  or  six  days.  In  one  of  my  cases  death  occurred 
on  the  fourth  day,  in  one  on  the  fifth,  in  one  on  the  sixth, 
in  two  on  the  seventh,  and  in  one  on  the  eighth."  Dr.  J. 
Lewis  Smith  gloomily  and  yet  accurately  remarks  that  "when 
the  croupy  cough,  voice  and  respiration  are  observed,  he  will 
seldom  err  who  predicts  a  fatal  result  within  a  week,  and 
often  death  follows  in  two  or  three  days."  Oertel's  experi- 
ence is  "  that  diphtheria  of  the  larynx  and  lower  air  passages 
in  children  usually  run*  its  course  in  a  few  days ;  in  from 
two  to  eight  days,  or  more  rarely  as  late  as  the  tenth  or 
twelfth  day,  either  a  fatal  termination  or  convalescence  takes 
place." 

Dr.  Charles  West  gives  the  following  interesting  table  of 
27  cases  of  diphtheria  in  which  death  took  place  chiefly  from 
the  affection  of  the  larynx  : 

The    child    died    on    the    2nd    day    in    1. 
•  ••         .  "         '•  "  3rd 

4th 

' 5th 

6th 

7th 

3th 

9th 
10th 
nth 

12th 

"       13th 

14th 

I5tli 

2ISt 
23rd 

My    own    experience     is    very    similar    to    that    of    the 


DIPHTHERITIC    CROUP.  249 

distinguished  authors  just  quoted.  Much  depends  on  the 
malignancy  of  the  general  disease,  but  when  diphtheritic 
croup  is  really  developed,  death  usually  takes  place  within  a 
week  of  the  invasion  of  the  laryngeal  symptoms.  Indeed,  it 
may  be  said  to  be  a  general  rule  that  when  death  takes  place 
in  diphtheria  within  a  week,  it  is  by  extension  of  the  disease 
to  the  larynx.  Very  few  croupous  cases  live  to  see  the 
commencement  of  the  second  week,  for,  when  death  takes 
place  after  the  expiration  of  the  first  week,  it  is  very 
frequently  caused  by  exhaustion.  It  is  true  that  I  have  seen 
the  disease  developed  as  late  as  Dr.  Hillier  has  observed, 
but  then  it  could  always  be  traced  to  an  accidental  exposure 
to  cold. 

In  diphtheritic  croup  death  may  be  the  result  of  a  severe 
and  long-continued  spasm  of  the  glottis,  which  seems  to  be 
of  the  essence  of  the  paroxysms  already  described,  or  it  may 
arise  from  a  purely  mechanical  blocking  up  of  the  larynx, 
trachea  or  bronchi  by  the  diphtheritic  membrane,  or,  lastly, 
death  may,  according  to  Oertel,  result  from  insufficient 
decarbonization  of  the  blood,  due  to  its  unequal  distribution;" 
this  inequality  in  the  distribution  of  the  blood  is  due  to  the 
fact  that  emphysema  and  anaemia  have  established  them- 
selves in  the  parts  open  to  the  circulation  of  air,  while  in 
the  collapsed  parts,  to  which  the  air  does  not  have  access, 
there  is  hyperaemia.  Later  in  the  course  of  the  disease, 
pneumonia  may  set  in,  or  pulmonary  oedema,  and  if  the 
patient  should  surmount  these  manifold  dangers  there 
remains  the  blood-poisoning  of  the  primitive  disease,  which 
may  prove  fatal  even  months  after  all  danger  from  the 
respiratory  organs  has  passed  away.  As  a  general  rule,  it  is 
rare  to  find  one  of  these  causes  of  death  acting  singly  and 
alone,  for  the  diphtheritic  blood-poisoning  is  an  almost 
invariable  factor  in  the  fatal  result. 

If  the  throat  is  examined  in  the  early  stages,  the  fauces, 
soft  palate  and  tonsils  will  either  be  found  to  be  of  an 
universal  purplish  red,  or  marked  and  blotched  with  the 
same  hue.     This  redness  is  succeeded  by  a  thick,  albuminous 


250  I'irii tiii:i;i  m     i  fci  >1  I  . 

lymph,  which  is  more  abundant  at  the  base  «>f  the  arch  of 
the  palate  than  above  it,  looking  as  if  it  had  extended  from 
the  larynx.  The  contrary  is  the  case  when  the  larynx  is 
secondarily  affected,  for  then  the  lymph  is  more  copious  at 
the  summit  of  the  arch  of  the  palate. 

Dr.  Paul  Guttmann,  of  Berlin,  observes  that  "  Very  young 
children,  who  are  most  frequently  attacked  by  laryngeal 
diphtheritis,  can  very  seldom  be  subjected  to  laryngoscopic 
examination  ;  the  affection,  however,  can  usually  be  diagnosed 
without  it,  as  we  know  from  experience  that  symptoms  of 
stenosis  of  the  glottis  (crowing  and  prolonged  inspiration), 
and  hoarseness  or  aphonia,  when  they  present  themselves 
along  with  diphtheritis  of  the  pharynx,  are  always  due  to  an 
extension  of  the  disease  to  the  larynx.  Even  when  the 
pharyngeal  diphtheritis  is  wanting  the  above-mentioned 
indications,  when  observed  in  young  children  in  districts  in 
which  diphtheritis  is  prevalent  in  an  epidemic  form,  generally 
warrant  one  in  assuming  confidently  the  diphtheritic  nature 
of  the  laryngeal  affection."  Oertel  gives  the  following  sketch 
of  the  results  of  the  laryngoscopic  examination  made  in 
children  sick  with  laryngeal  diphtheria  :  "  All  the  parts  of 
the  larynx  will  be  found  intensely  reddened  and  swollen,  the 
epiglottis  thickened  to  twice  its  natural  size,  and  the  yellow 
colour  of  the  cartilage,  which  normally  shows  through  its 
covering,  no  longer  distinguishable  ;  the  aryteno-epiglottidean 
folds,  the  false  and  true  cords,  are  greatly  swollen,  and  are 
covered,  more  or  less,  with  a  grayish-white  exudation,  or  the 
interior  of  the  larynx  itself  is  lined  with  a  white,  leather-like 
covering,  and  the  glottis  is  narrowed.  Tenacious  exudation 
and  purulent  mucus,  which  push  up  from  the  deeper  parts 
of  the  air-passages,  often  adhere  between  the  vocal  cords, 
and  are  driven  up  and  down  in  the  narrow  cleft  by  the 
forced  respiration." 

It  is  well  to  remember  that,  even  when  the  lungs  are  not 
directly  implicated,  the  respiratory  murmur  is. so  overwhelmed 
by  the  loud,  laryngeal  sounds  that  no  vesicular  murmur  can 
be  detected  by  auscultation. 


DIPHTHERITIC    CROUP.  2$  I 

The  pseudo-membranes  found  in  the  larynx  vary  much  in 
consistence,  extent  and  appearance.  Sometimes  it  is  soft, 
gelatinous  and  almost  liquid,  lying  loose  in  the  throat,  almost 
like  a  clot  of  cream,  with  its  particles  so  soft  and  so  little 
connected  with  each  other  that  it  almost  seems  a  misnomer 
to  apply  the  term  '  pseudo-membrane  '  to  it.  At  other 
times  it  resembles  a  fragment  of  moist  kid  glove  leather — 
dense,  elastic,  coherent,  and  as  thick  as  a  silver  half-dollar. 
I  remember  examining  one  pseudo-membrane,  in  i860,  the 
upper  part  of  which  was  a  quarter  of  an  inch  in  thickness, 
and  of  horny  hardness.  It  was  lying  almost  loose  in  the 
fauces,  and  on  being  removed,  it  was  perfectly  reproduced 
in  twenty  hours.  Between  these  extremes  one  meets  with 
membranes  of  great  variety  as  regards  thickness,  cohesion 
and  appearance.  The  more  liquid  membranes  are  whitish  or 
yellowish-white  in  color,  while  the  denser  ones  are  grayish, 
or  ash-coloured,  and  sometimes  brown  or  blackish. 

On  examining,  after  death,  the  bodies  of  those  who  have 
died  of  diphtheria  of  the  air  passages,  the  epiglottis  is  often 
found  to  be  so  enormously  swollen  as  to  close  the  entrance 
to  the  windpipe.  It  is  also  covered  on  both  sides,  or  on  one 
only,  with  the  characteristic  exudation,  on  removing  which, 
small  points  of  ulceration  are  found  studding  the  surface. 
This  exudation  is  not  an  effusion  upon  the  free  surface  of 
the  mucous  membrane,  but  an  exudation  zvitJiin  the  tissue 
as  well,  and  it  often  destroys  both  mucous  membrane  and 
epithelium.  The  larynx  is  lined  with  a  similar  pseudo- 
membrane,  generally  whiter  than  the  diphtheritic  membrane 
found  on  the  tonsils  and  pharynx,  on  removing  which,  an 
ulcerous  surface,  raw  and  sore,  is  seen,  for  diphtheria — at 
least  in  its  local  manifestations  in  the  fauces  and  air  passages 
— is  simply  a  specific  inflammation  with  partial  necrosis  and 
sloughing  of  the  mucous  membrane.  The  diphtheritic 
membrane  is  not  so  easily  pulled  off  as  the  pseudo-membrane 
of  true  croup,  for  in  the  latter  disease  an  effusion  between 
the  mucous  membrane  and  the  pseudo-membrane  is  an  effort 
of  nature  to  cure  the  disease.  But  in  diphtheritic  croup 
the  mucous  membrane  dies,  if  the  case  lasts  any  time. 


2-?2  DIPHTHER]  lie    CRi  n  E>. 

Dr.  Charles  West  remarks  that  he  has  "  in  no  instance 
observed  false  membranes  extending  below  the  larynx,"  but, 
in  common  with  many  other  physicians,  I  have  .seen  complete 
casts  of  the  trachea,  bronchi  and  bronchial  tubes,  even  to 
the  third  bifurcation.  In  the  upper  part  of  the  trachea  the 
pseudo-membrane  is  similar  to  that  Lining  the  larynx,  but  as 
it  descends  it  becomes  thinner  and  less  consistent,  till  it 
tapers  off  to  a  very  thin  and  transparent  pellicle.  In  some 
ten  or  twelve  cases  I  have  noticed  blood  that  had  been 
accidentally  drawn,  and  it  was  always  of  a  dark  brownish 
hue  and  deficient  in  coagulability. 

Is  pseudo-membranous  croup  identical  zvith  diphth-eritic 
croup  t  Is  each  case  of  pseudo-membranous  croup  nicrcly  a 
sporadic  case  of  laryngeal  diphtheria  ?  This  is  one  of  the 
burning  questions  in  pathology,  and  yet  it  has  been  strangely 
ignored  by  almost  all  the  authors  of  our  school  who  have 
written  on  diphtheria  or  on  croup.  The  question  at  issue  is 
thus  temperately  stated  by  Drs.  Meigs  and  Pepper:  "But 
further,  our  personal  experience  constrains  us  to  state  that 
the  differences  between  the  two  forms  of  membranous-croup 
above  enumerated  have  not  seemed  to  us  sufficiently  marked 
and  constant  to  positively  establish  their  essential  diversity  ; 
and  that  it  is  our  decided  opinion  that  the  vast  majority  of 
the  cases  usually  termed  pseudo-membranous  laryngitis 
(pseudo-membranous  croup)  are,  in  reality,  instances  of 
primary  laryngeal  diphtheria  (diphtheritic  croup),  in  which 
the  constitutional  symptoms  are  not  grave,  and  where  the 
faucial  deposit  has  been  very  slight  and  perhaps  even  over- 
looked." 

As  already  remarked,  this  view  is  held  by  the  great  mass 
of  French  pathologists,  a  large  number  of  the  Germans,  and 
a  small  but  respectable  minority  of  the  English,  while  on 
this  continent  the  contrary  view  is  very  generally  maintained. 
Another  view  is  taken  of  this  deeply  interesting  and 
important  subject  by  a  large  body  of  medical  men,  who 
look  upon  diphtheria,  in  the  words  of  Dr.  Charles  West,  as 
being  "  a  second  form  of  disease,  resembling  croup  in  some 


DIPHTHERITIC    CROUP.  253 

respects,  though  differing  in  others,  alike  but  not  the  same." 
This  is  the  view  held  by  the  present  writer,  who  considers 
that  while  the  distinction  between  the  two  maladies  is 
sufficiently  marked  in  typical  cases,  that  in  a  small  number 
of  instances  there  is  a  tendency  in  one  disease  to  run  into 
the  other,  precisely  as  every  experienced  practitioner  has 
met  with  cases  of  disease  which  taxed  his  diagnostic  skill  to 
decide  whether  they  were  small-pox  or  chicken-pox.  Further, 
it  is  freely  conceded  that  diphtheria  implicating  the  air- 
passages,  must,  in  the  very  nature  of  things,  produce 
symptoms  strikingly  similar  to  those  of  croup,  but  that  by  no 
means  proves  their  identity,  for  a  foreign  body  in  the  larynx 
simulates  croup  very  closely.  But,  as  a  very  general  rule, 
the  non-epidemic,  non-contagious,  sthenic,  localized  inflam- 
mation of  true  croup  is  readily  distinguished  from  the 
epidemic,  contagious,  asthenic,  general  disease  which  we 
style  diphtheritic  croup,  in  which  the  local  inflammation  is 
merely  one  of  the  many  incidents  of  a  deeply-pervading 
constitutional  affection. 

Dr.  Jacobi  of  New  York  propounds  the  following  queries : 
"  Can  pseudo-membranous  croup  be  distinguished  from 
laryngeal  diphtheria?  Ought  these  terms  to  be  preserved 
separately  ?  Are  they  different  processes  ?  Let  us  suppose 
two  cases  of  membranous  impediment  in  the  larynx,  the  one 
with,  the  other  without  membrane  in  the  pharynx,  the  other 
symptoms  being  the  same,  is  one  "  diphtheria  of  the  larynx," 
and  the  other  "  croup  "  ?  Suppose  again,  a  membranous 
stenosis  of  the  larynx,  to  which  is  only  later  added  a 
membrane  of  the  pharynx,  was  the  case  originally  one  of 
"  croup  "  which  became  a  "  diphtheria  "  later  on  ?  Thirdly, 
take  two  cases  of  laryngeal  stenosis,  one  with  symptoms  of 
suffocation  only,  the  other  having  these  symptoms  together 
with  adynamia;  is  the  latter  "  diphtheria"  alone,  the  former 
only  "  croup  "  ?  In  my  opinion,  it  is  just  as  little  possible  to 
differentiate  these  diseases  according  to  the  seat  of  the 
morbid  product,  as  it  is  justifiable  to  deny  the  title 
diphtheria   to    membranous   pharyngitis   when  few  general 


254  Dl  I'll  i  III  I'll  \r    CROUP. 

symptoms,  such  as  fever,  debility  and  collapse,  happen  to  be 
present."  To  these  queries  Rokitansky's  definitions  are  a 
sufficient  reply  :  "  Croup  is  a  fibrinous  exudation  effused 
in  a  liquid  form,  and  coagulating  on  the  surface  of  the 
mucous  membrane,  this  being  unaltered  or  nearly  so,"  and, 
"  Diphtheria  is  a  necrotic  process,  consisting  in  infiltration 
of  the  mucous  membrane,  accompanied  by  exudation  and 
followed  by  sloughing,"  and  the  chief  point  of  resemblance 
is  that  both  are  manifestations  of  an  inflammatory  condition 
tending  to  exudation.  As  Herschel  clearly  points  out, 
croup  is  a  plastic  disease,  while  diphtheria  is  a  gangrenous 
one,  and  this  dictum  holds  good,  even  though  the  diagnosis 
of  some  few  cases  baffles  the  most  experienced. 

Hirschel  points  out  that  while  in  diphtheria  the  sub-mucous 
tissue  is  affected,  besides  the  mucous  membrane,  in  croup 
only  the  mucous  membrane  is  the  seat  of  the  disease,  while 
L.  Fleischmann  considers  that  the  membrane  of  croup  is  a 
true  pseudo-membrane  lying  on  the  surface  of  the  mucous- 
membrane,  from  which  it  can  be  removed,  while  the 
membrane  of  diphtheria  is  never  a  true  croup-membrane, 
but  deposits  consisting  of  degenerated  and  exfoliated 
epithelium,  fungi  and  detritus.  Dr.  T.  H.  Green  observes, 
"  It  is  difficult  in  many  cases  to  draw  any  line  of  demarcation 
between  the  histological  changes  occurring  in  diphtheria  and 
those  of  croup.  In  diphtheria,  however,  the  sub-mucous 
tissue  usually  becomes  more  extensively  involved,  so  that 
the  false  membrane  is  much  less  readily  removed  The 
circulation  also  becomes  so  much  interfered  with  that 
portions  of  the  tissue  lose  their  vitality,  and  large  ash-colored- 
sloughs  are  formed,  which,  after  removal,  leave  a  consider- 
able loss  of  substance."  Again,  on  removing  the  membrane 
of  croup,  the  mucous  membrane  remains  smooth  and 
uninjured,  while  in  diphtheritic  croup,  on  removing  the 
exudation,  the  surface  is  ulcerated  and  gangrenous.  Dr.  A. 
W.  Barclay,  however,  remarks  that  "  the  fibrinous  exudation, 
so  unusual  in  inflammation  of  mucous  membranes,  is  also 
apparently  identical  ;  but  as  far  as  we  know,  the  cause  is 
different." 


DIPHTHERITIC    CROUP.  255 

Dr.  Morell  Mackenzie  ridicules  the  idea  of  supposing 
"  that  there  are  two  kinds  of  pellicular  inflammation  of  the 
larynx,  one  in  which  the  cause  is  the  diphtheritic  poison,  and 
the  other  in  which  the  cause  is  some  other  undiscovered 
influence,  is  totally  opposed  to  all  probabilities  ;"  but,  as  was 
pointed  out  by  the  croup-diphtheria  Committee  of  the  Royal 
Medico-Chirurgical  Society,  "Membranous  inflammation, 
confined  to  or  chiefly  affecting  the  larynx  or  trachea,  may 
arise  from  a  variety  of  causes,  as  follows :  (a.)  From  the 
diphtheritic  contagion  ;  (b.)  by  means  of  foul  water,  of  foul 
air,  or  other  agents,  such  as  are  commonly  concerned  in  the 
generation  or  transmission  of  zymotic  diseases ;  (c.)  as  an 
accompaniment  of  measles,  scarlatina  or  typhoid,  independ- 
ently of  any  ascertainable  exposure  to  the  especial  diphther- 
itic infection ;  (d.)  it  is  stated,  on  apparently  conclusive 
evidence,  that  membranous  inflammation  of  the  larynx  and 
trachea  may  be  produced  by  various  accidental  sources  of 
irritation — the  inhalation  of  hot  water  or  steam,  the  contact 
of  acids,  the  pressure  of  a  foreign  body  in  the  larynx,  and  a 
cut  throat." 

The  mode  of  death  in  the  two  diseases  is  strikingly 
different,  though,  as  a  matter  of  course,  the  termination  of 
all  cases  when  death  results  from  apncea  is  identical.  "  In 
croup,"  as  Dr.  Prosser  James  points  out,  "  the  exudation 
endangers  life,  both  by  inducing  spasmodic  closure  of  the 
glottis  and  by  mechanically  impeding  the  entrance  of  air  into 
the  lungs;  the  patient  dies  suffocated;  in  diphtheria  it  is 
associated  with  intense  depression  of  the  vital  powers,  such 
as  we  see  in  malignant  fevers,  and  speaks  plainly  of  blood- 
poisoning;  the  patient  dies  exhausted." 

Dr.  Alfred  Meadows,  of  London,  concludes  his  essay  on 
the  identity  of  the  two  diseases  by  remarking,  "At  any  rate, 
we  must  admit  thai  they  both  are  blood  diseases"— which  we 
concede  without  demur.  Scarlatina  and  syphilis  are  both 
"  blood  diseases,"  but  few  would  draw  arguments  in  favor  of 
the  identity  of  these  diseases  from  that  fact. 

Another   point  of  difference    is   the    site  of   the  disease 


DIPHTHERITIC    CROUP. 

I  diphtheritic  croup,  in  the  vast  majority  of  cases,  commences 
in  the  pharynx  and  extends  thence  to  the  air  passages,  while 
pseudo-membranous  croup  commences  in  the  larynx,  and,  if 
it  spreads  at  all,  it  extends  to  the  trachea  and  bronchial 
tubes.  In  croup  the  earliest  symptom  is  that  of  stridulous 
voice  and  respiration  ;  in  diphtheria  the  uneasiness  is  first 
felt  in  the  fauces.  Dr.  Hauner,  of  Munich,  says  that  "  true 
croup  always  commences  in  the  larynx  " — it  would  be  more 
correct  to  say  that  it  generally  commences  in  the  larynx,  while 
diphtheritic  croup  generally  commences  in  the  pharynx. 

Dr.  Morell  Mackenzie  says:  "The  fact  is,  that  croup  is  a 
disease  which  commonly  commences  in  the  pharynx,  and 
only  in  about  10  or  12  per  cent,  of  cases  originates  in  the 
larynx  or  trachea."  In  a  large  number  of  cases  of  pseudo- 
membranous croup,  I  observed  little  islands  of  exudation  of 
a  pearly  lustre  in  the  neighborhood  of  the  glottis,  but  that 
appeared  at  the  same  time  as  the  exudation  in  the  larynx, 
and  sometimes  even  later.  Very  seldom  have  I  observed 
the  pharyngeal  exudation  preceding  the  laryngeal,  certainly 
not  more  than  in  five  per  cent. -of  the  whole  number.  No 
one  could  confound  the  water-white  of  the  croup  exudation 
with  the  milk-white  of  the  diphtheritic  one.  Dr.  Mackenzie 
adds,  "  Difference  of  site,,  moreover,  in  a  constitutional 
disease,  does  not  constitute  a  specific  difference.  Here  the 
constitutional  nature  of  pseudo-membranous  croup  is  assumed 
to  be  the  same  in  kind  as  the  constitutional  nature  of  diph- 
theritic croup — to  me  they  seem  to  differ  as  much  as 
croupous  pneumonia  differs  from  gangrene  of  the  lungs. 

"  My  idea  of  the  problem  to  be  solved  is,  in  fact,  this :  It 
must  be  admitted  that  the  diphtheritic  poison  is  capable  of 
giving  rise  to  a  plastic  inflammation  of  the  larynx,  apart 
from  the  existence  of  any  similar  affection  of  the  pharynx. 
But  there  is  good  reason  to  believe  that  during  epidemics  of 
diphtheria,  the  cases  in  which  this  occurs  are,  in  the  highest 
degree,  exceptional.  If,  therefore,  it  can  be  shown  that  in 
the  practice  of  a  general  hospital  the  cases  of  plastic  laryn- 
gitis, of  uncertain  origin,  bear  a  large  proportion  to  the  total 


DIPHTHERITIC    CROUP.  257 

number  of  cases  of  diphtheria,  there  will  be  a  strong 
probability  that  the  majority  of  the  former  cases  are 
dependent  upon  some  other  cause  than  the  diphtheritic 
poison  " — {Diphtheria  and  Croup,  by  W.  H.  Lamb,  M.  B., 
and  C.  Hilton  •  Fagge,  M.  D.,  "  Guy's  Hospital  Reports," 
1877). 

True  croup  is  most  frequently  caused  by  the  sudden 
passage  from  warm  to  cold  air,  and  is  often  occasioned  by 
sleeping  in  very  cold  bed-chambers  after  having  been  all  day 
in  hot  rooms.  Diphtheritic  croup  is  the  manifestation  in 
the  larynx  of  a  blood  disease  ;  and  whatever  effect  external 
cause  may  have  in  bringing  about  diphtheria  in  general,  they 
have  very  little  in  producing  the  laryngeal  variety.  True 
croup  almost  invariably  begins  with  catarrh  and  fever,  and 
this  in  exact  ratio  with  the  severity  of  the  local  symptoms  ; 
difficulty  in  swallowing  is  very  rare,  is  always  very  slight 
When  it  does  occur,  and  it  is  always  dependent  on  the 
laryngeal  affection.  In  diphtheria  catarrh  is  rare,  for  the 
fetid  sanies  which  flows  from  the  nostrils  and  mouth  can 
hardly  be  called  catarrhal,  and  from  the  very  inception  signs 
of  deep-seated  constitutional  mischief  are  evident ;  sore 
throat  and  difficulty  in  swallowing  precede  the  laryngeal 
affection. 

Dr.  Edmonds,  of  St.  Louis,  points  out  that  while  "  croup 
is  bold,  abrupt  and,  as  it  were,  outspoken  in  manner  and 
character,  diphtheria  is  sneaking,  insidious  and  undefined  in 
its  mode  of  approach,"  and  this,  so  far  as 'my  experience 
extends,  holds  almost  universally  good.  Dr.  L.  Fleischmann 
remarks  that  while  croup  most  frequently  affects  the  mucous 
membrane  of  the  air  passages,  diphtheria  frequently  has 
"  multilocular  invasion,"  the  fauces,  nose,  genitals,  intestines 
and  the  skin  being  affected  simultaneously.  Again,  the 
kidneys  and  intestines  are  normal  in  croup,  while  in  the 
laryngeal  form  of  diphtheria  they  are  often  involved. 

Dr.  Hillier  remarks,  "  It  appears  to  me  as  impossible  to 
maintain  that  croup  is  merely  a  local  disease,  as  that 
pneumonia  is  merely  local,  or  catarrh,  both  of  which   are 


258  DIPHTHERITIC    CR<  U   r. 

generally  indications  of  a  morbid  constitutional  state." 
Precisely  so,  croup  and  pneumonia  arc  strictly  analogous 
diseases,  and  the  "morbid  constitutional  state"  is,  in  both 
affections,  dependent  on  the  local  disease.  But  that  may 
be  freely  conceded  without  granting  the  identity  of  true 
croup  and  diphtheritic  croup. 

I  >i .  Morcll  Mackenzie  says,  "  It  is  true  that  in  croup  the 
general  symptoms  are  not  so  severe  as  when  the  membrane 
is  thrown  out  on  an  extensive  portion  of  the  pharynx.  This 
fact  admits  of  ready  explanation,  on  the  view  that  the  septic 
symptoms  are  in  part  secondary  to  the  local  processes."  But 
in  diphtheritic  croup,  the  septic  symptoms  precede  the  local 
process  in  the  vast  majority  of  cases,  and  I  have  rarely  seen 
diphtheria  attack  the  larynx  in  the  first  instance.  Again 
Dr.  Mackenzie  says,  "  When  the  primary  septic  *poisoning  is 
powerful,  the  constitutional  symptoms  are,  however,  as 
marked  in  so-called  croup  as  in  diphtheria."  No  other 
medical  observer  on  either  continent,  so  far  as  I  know,  has 
asserted  that  pseudo-membranous  croup  is  accompanied  or 
followed  by  constitutional  symptoms  similar  to  those  which 
accompany  diphtheritic  croup,  for,  as  Dr.  Edmonds  ably 
points  out,  "  In  diphtheria  the  diseased  appearance  in  the 
larynx  or  trachea  is  simply  the  outcropping  of  a  previous 
constitutional  taint.  The  outcropping  is  not  confined  to  the 
larynx  or  trachea,  but  may  show  itself  in  the  nose,  throat, 
eyes,  ears,  and  even  upon  the  cutaneous  surface,  wherever 
there  may  be  the  slightest  break  of  integrity  or  denuding  of 
surface." 

True  croup,  then,  is  a  local  inflammation  of  an  exudative 
character  accompanied  by  a  purely  inflammatory  fever,  while 
diphtheritic  croup  is  originally  a  blood  poisoning,  and  the 
laryngeal  disease  is  what  Hahnemann  would  call  "a  local 
manifestation  "  of  that  blood  poisoning — hence,  in  a  majority 
of  cases  of  true  croup  the  pharynx  is  healthy,  or  almost 
healthy,  while  in  a  majority  of  cases  of  diphtheritic  croup 
the  pharynx  is  diseased. 
|r  Another  important  distinction  between  the  two  diseases 


DIPHTHERITIC    ('Roup.  259 

is,  that  while  true  croup  is  a  sthenic  inflammation,  diphther- 
itic croup  is  accompanied  by  fever  of  an  adynamic  type.  In 
opposition  to  this,  Dr.  Morell  Mackenzie  asserts  that  "  cases 
of  sthenic  croup  are  very  rarely  met  with,  and  the  same 
remark  applies  to  diphtheria."  All  the  text-books,  all  the 
observers  of  both  continents,  describe  the  fever  of  pseudo- 
membranous croup  as  being  sthenic,  and  I  venture  to  say 
that  Dr.  Mackenzie  stands  alone  in  his  position,  and  though 
he  says  that  "  distinctions  based  upon  differences  of  type  in 
the  two  diseases  can  have  no  weight,"  it  is  quite  certain  that 
all  diagnosis  depends  upon  the  detection  of  just  such 
"differences  of  type."  While,  then,  true  croup  commences 
with  inflammatory  fever  of  a  very  pronounced  type,  diph- 
theritic croup  is  accompanied  by  fever  of  a  typhoid  or 
adynamic  type. 

Another  important  difference  is  that  in  croup  the  cervical 
lymphatic  glands  are  not  swollen,  while  in  diphtheritic  croup 
the  cervical  glands  are  inflamed  and  consequently  enlarged. 
Dr.  Mackenzie  admits  that  "  the  cervical  glands  are  not  often 
affected  in  croup,  because  the  mucous  'membrane  of  the 
larynx  has  no  communication  with  the  superficial  cervical 
glands ;  on  the  other  hand,  as  stated  above,  there  is  an 
elaborate  connection  between  the  pharynx  and  the  lymphatic 
glands,"  and  he  quotes  Luschka's  ingenious  explanation : 
"Whilst  the  lymphatics  of  the  mucous  membrane  of  the 
soft  palate,  of  the  tonsils  and  of  the  back  of  the  pharynx 
have  very  free  communications  with  the  numerous  glands 
below  the  angle  of  the  jaw,  the  absorbent  vessels  of  the 
mucous  membrane  of  the  larynx  and  trachea  are  conveyed 
only  to  the  solitary  gland  just  below  the  greater  horn  of  the 
hyoid  bone,  and  the  small  gland  at  the  side  of  the  trachea." 
The  fact  is,  that  in  pseudo-membranous  croup  the  cervical 
glands  are  swollen,  especially  those  at  the  outer  border  of 
the  sterno-mastoid  muscle  ;  but,  as  Dr.  L.  Fleischmann  accu- 
rately points  out,  in  croup  there  is  swelling  of  the  glands, 
but  almost  never  suppuration  of  fetid  character,  while  in 
diphtheria  suppuration  of  the  glands  is  of  frequent  occur- 
rence. 


DIPHTHERITIC    CROUP. 

Another  point  of  difference,  formerly  looked  upon  us  all 
but  conclusive,  and  still  much  relied  upon  by  excellent 
observers,  is  that  while  albuminuria  is  present  in  diphtheritic 
croup,  it  is  not  present  in  pseudo-membranous  croup.  Even 
as  late  as  [880,  Dr.  Henry  Hartshorne,  of  Philadelphia,  affirms 
that  "  croup  is  not  followed  by  albuminaria,"  and  Dr.  Squire 
states  that  in  drawing  the  diagnostic  lines  between  the  two 
morbid  states,  "  the  presence  of  albumen  in  the  urine  is 
conclusive"  On  the  other  hand,  Dr.  Morell  Mackenzie  affirms 
that  "  in  croup  albuminuria  is  often  found."  Dr.  Hillier  says 
that  "albumen  has  been  found  in  the  urine  of  patients  with 
croup ;"  while  Dr.  Alfred  Meadows,  of  London,  states  that 
"  in  mild  cases  of  diphtheria  there  is  often  no  albuminuria, 
while  in  severe  cases  of  croup  it  is  not  unfrequently  present." 
But  the  force  of  all  these  observations,  undoubtedly  correct 
as  they  certainly  are,  is  broken  by  the  fact  that  the  elaborate 
researches  carried  on  under  the  auspices  of  the  Royal  Medico- 
Chirurgical  Society,  of  London,  conclusively  prove  that 
albuminuria  occurs  in  cases  of  laryngitis  in  which  no 
membrane  is  formed — that  is,  in  simple  laryngitis  which  is 
neither  croupous  nor  diphtheritic.  The  conclusion  seems  to 
be  that  albuminuria  is  relatively  less  frequent  in  pseudo- 
membranous croup  than  in  diphtheritic  croup,  but  that  as  it 
also  occurs  in  phases  of  laryngeal  disease  which  belong  to 
neither  of  these  classes,  this  criterion  must  be  looked  upon 
as  being  indecisive. 

One  of  the  principal  clinical  differences  is  that  while 
paralysis  occurs  after  diphtheritic  croup,  it  does  not  occur  in 
true  croup.  Dr.  Squire  says  that  "  paralysis  of  some  of  the 
muscles  of  vocalization,  deglutition  or  of  motion,  is  equally 
distinctive  of  diphtheria;"  Dr.  L.  Fleischmann  states  that 
in  croup  "paralysis  never  occurs,"  while  in  diphtheria,  "even 
in  mild  cases,  severe  nervous  disturbances  are  common  ;"  and 
J.  Solis  Cohen  gives  it  as  a  chief  point  of  difference:  "In 
croup  no  secondary  paralysis;  in  diphtheria  secondary 
paralysis  is  frequent." 

On    the    other   hand,    Dr.    Morell    Mackenzie    says    that 


DlPHTHERtTj*      CROUP.  261 

"  paralysis  is  rare  in  croup,  because  nearly  all  the  cases 
terminate  fatally,  but  it  is  occasionally  met  with  in  those 
that  survive  ;"  I  have  never  met  with  paralysis  after  true 
croup,  and  no  writer  on  the  disease  has  ever  mentioned  such 
a  thing,  and  Dr.  Mackenzie  is  describing  cases  which  nine- 
teen medical  men  out  of  twenty  would  call  diphtheritic 
croup.  Dr.  Hillier  remarks:  "Even  when  epidemics  of 
diphtheria  prevailed  in  former  times,  the  nervous  sequelae 
were  not  noted;  we  have  no  record  of  these  phenomena  till 
a  comparatively  recent  period.  It  is  quite  probable  that 
even  if  symptoms  of  disordered  innervation  had  followed 
sporadic  croup  in  as  large  a  proportion  of  cases  as  they 
follow  epidemic  diphtheria,  they  would  not  have  been 
connected  with  the  previous  illness,"  but  some  of  the  Spanish 
and  Sicilian  writers  describe  nervous  phenomena  following 
garrotilla,  and  it  would  be  strange,  indeed,  if  observers 
failed  to  connect  disordered  innervation  with  true  croup  in 
the  purely  hypothetical  case  stated  by  Dr.  Hillier.  Dr. 
Alfred  Meadows  observes :  "  Paralysis  is  frequently  absent, 
even  in  rather  severe  cases  of  diphtheria.  In  France  it  is 
said  that  paralysis  is  present  in  at  least  one-third  of  the  cases, 
while  in  England  it  does  not  occur  more  frequently  than  in 
ten  per  cent,  of  the  cases ;  therefore,  it  might  be  argued 
that  at  least  in  those  cases  where  this  symptom  is  absent, 
there  is  nothing  essentially  distinguishing  it  from  croup." 
Dr.  Meadows  does  not  affirm  that  paralysis  has  ever  been 
observed  to  follow  true  croup,  and  in  cases  of  diphtheritic 
croup,  when  paralysis  is  absent,  other  diagnostic  marks, 
equally  conclusive,  are  present.  Another  writer,  who  upholds 
the  doctrine  of  the  unity  of  these  diseases,  candidly  admits 
that  "  sporadic  cases  "■ — -by  which  he  means  cases  of  true 
croup — are  rarely  followed  by  paralysis  or  albuminuria,  and 
this  is  the  conclusion  of  a  vast  number  of  careful  and  impar- 
tial observers. 

True  croup  is  non-epidemic,  non-contagious  and  non- 
inoculable,  while  diphtheritic  croup — in  common  with  all 
manifestations  of  diphtheria — is  epidemic,  contagious  and 
inoculable. 


mm  PHERITN     CR<  >UP. 

Jn  [879  the  Royal  Medico-Chirurgical  Society  of  London 
appointed  a  committee  to  examine  the  relations  existing 
between  croup  and  diphtheria,  and  in  the  very  interesting 
report  the  following  passages  bear  on  this  question  : 
"  Membranous  inflammation,  chiefly  of  the  larynx  and 
trachea,  to  which  the  name  'membranous  croup'  would 
commonly  be  applied,  ma}-  be  imparted  by  an  influence, 
epidemic  or  of  other  sort,  which  in  other  persons  has 
produced  pharyngeal  diphtheria.  And,  conversely,  a  person 
suffering  with  the  membranous  affection,  chiefly  of  the  air- 
passages,  such  as  would  commonly  be  termed  membranous 
croup,  may  communicate  to  another  a  membranous  condition, 
limited  to  the  pharynx  and  tonsils,  which  will  be  commonly 
regarded  as  diphtheritic."  Gerhardt  asserts  that  he  has, 
himself,  "  described  a  sporadic  case  which  proved  contagious," 
which  may  well  be  the  case  if  the  sporadic  case  was 
diphtheritic.  Dr.  Meadows  observes,  "we  know  that  croup 
does  sometimes  occur  epidemically,  and  if  it  be  not 
contagious  so  neither  is  it  certain  that  diphtheria,  when  it 
attacks  a  number  of  persons  in  the  same  house  or  locality, 
is  really  communicated  ;  for  the  fact  may  be  due  to  the 
exposure  of  those  affected  to  the  same  influence  and  at  the 
same  time."  To  this  it  is  sufficient  to  reply  that  it  is 
quite  certain  that  diphtheria  is  contagious,  but  no  sufficient 
evidence  has  yet  been  adduced  to  prove  that  croup  possesses 
the  same  quality,  and  the  onus  probandi  lies  with  those  who 
assert  that  it  is  contagious. 

Dr.  Edmonds  says,  "  Diphtheria  is  a  zymotic,  constitutional 
blood  disease,  is  in  many  instances  believed  to  be  contagious, 
is  undoubtedly  inoculable  by  application  of  matter  from  a 
diphtheritic  part  to  the  mucous  or  denuded  surface  of  a 
healthy  subject."  Dr.  Charles  West  points  out  that  while 
"  croup  is  influenced  by  climate  and  season,  is  endemic  in 
some  localities,  but  not  epidemic  nor  contagious,  diphtheria 
is  independent  of  climate  or  season,  contagious  and  often 
epidemic."  Dr.  L.  Fleishmann  observes  that  while  "  in  croup 
there     is    no    infection    of    the    blood,    with    corresponding 


DIPHTHERITIC    cut  Mr.  263 

symptoms  depending  thereon,  in  diphtheria  there  is  infection 
of  the  bjood  and  fatty  degeneration  of  the  striped,  muscular 
tissue,  especially  that  of  the  heart,  and  he  adds  that  while 
croup  is  not  inoculable,  diphtheria  is  inoculable.  Hirschel's 
experience  is  that  while  diphtheria  is  contagious  and  mostly 
epidemic,  croup  is  not  contagious,  and  is  mostly  sporadic. 

Steiner's  views  on  this  point  are  valuable,  and  he  concludes 
that  "  the  attempt  to  distinguish  croup  and  diphtheria  as 
two  entirely  distinct  diseases  has  been  unsuccessful,  both 
from  an  anatomical  and  from  a  clinical  standpoint,"  yet  he 
admits  that  "  primary  true  croup  is  not  a  contagions  disease, 
although  it  is  so  regarded  by  Bohn,  Gerhardt  and  others. 
Diphtheritic  croup,  however,  possesses  this  quality  in  a  high 
degree."  Dr.  Hillier,  too,  asserts  that  " epidemic  croup"  is 
ahuays  dipJitJieria — which  is  precisely  the  conclusion  of  the 
present  writer. 

True  croup  is  a  disease  of  cold  weather ;  diphtheritic 
croup  ravages  in  all  weathers  and  in  all  seasons.  Croup  is 
caused  almost  solely  by  climatic  influences,  although  at  times 
it  is  endemic ;  diphtheria  is  favored  by  everything  which 
promotes  the  growth  of  spores,  as  crowded  dwellings, 
personal  uncleanliness,  and  so  forth. 

True  croup  rarely  occurs  more  than  once  in  the  same 
patient,  but  it  is  quite  common  for  children  to  have  several 
attacks  of  diphtheria.  As  to  age,  true  croup  appears  much 
earlier  than  diphtheritic  croup.  True  croup  is  almost 
peculiar  to  children ;  adults  as  well  as  children  are  the 
victims  of  diphtheritic  croup.  Dr.  Alfred  Meadows  says  : 
"  In  regard  to  croup  seldom  or  never  attacking  adults,  while 
diphtheria  frequently  does,  this  can  hardly  be  relied  upon, 
because  the  same  may  almost  be  said  of  scarlatina."  Adults 
are  seldom  attacked  with  scarlatina,  simply  because  they 
have  passed  through  that  ordeal  in  youth ;  would  Dr. 
Meadows  affirm  that  adults  are  free  from  croup  because  they 
have  had  it  in  youth?  Dr.  Hillier  ingeniously  argues  that 
"  when  diseases  become  epidemic  they  are  more  liable  to 
attackadults,  who  escape  when  the  disease  is  only  sporadic," 


.?"!  DIPHTHERITIC    CROUP. 

hut  this  is  a  theory  as  yel  unsupported  by  facts  and  figures. 

I  have  never  observed  in  true  croup  the  scarlatiniforffl 
eruption  so  often  seen  in  diphtheritic  croup,  and  Dr.  Lyon, 
of  Connecticut,  points  out  that  in  croup  pseudo-membranes 
of  the  skin  are  never  observed,  while  in  diphtheria  pseudo- 
membranes  of  the  skin  are  occasionally  observed. 

Dr.  Ludlam,  of  Chicago,  writes  as  follows:  "The  dyspnoea 
in  croup  is  paroxysmal,  and  invariably  worse  at  night.  There 
is  a  true  spasm  of  the  laryngeal  and  tracheal  muscular 
fibres.  At  intervals  the  patient  breathes  almost  naturally. 
In  a  few  moments,  especially  if  permitted  to  sleep,  he  is  in 
a  fit  of  suffocation  again,  which,  by-and-by,  alternates  with 
relative  repose.  The  ease  and  freedom  of  the  respiratory 
movements  in  diphtheria  vary  considerably  at  intervals,  but 
the  intervals  occur  irregularly  during  the  day  as  well  as  at 
night,  and  the  relief  afforded  by  them  is  less  marked  than  in 
the  case  of  croup.  In  true  croup  a  trembling,  vibratory 
sound  may  often  be  heard  on  auscultation,  denoting  the 
presence  of  floating  false  membrane,  but  the  characteristic 
auscultatory  indication  of  diphtheritic  croup  is  a  soft  gurg- 
ling sound,  similar  to  the  cavernous  rale  of  phthisis.  Dr. 
J.  Solis  Cohen  remarks  that  in  croup  there  is  no  weakening 
of  the  heart's  action  ;  the  pulse  frequently  strong  and  hard, 
while  in  diphtheria  there  is  marked  weakening  of  the  heart's 
action ;  pulse  never  strong  and  hard,  even  though  rapid 
and  full. 

Finally,  it  is  a  matter  of  frequent  observation  that  while 
in  croup  the  general  health  is  rapidly  reestablished,  a 
complete  recovery,  without  sequelae,  following  the  cure  of 
the  local  disease,  in  diphtheritic  croup  the  convalescence  is 
remarkably  slow  and  tedious,  with  annoying  sequela:  lasting 
for  months  and  even  years. 

Monti  considers  croupous  laryngitis  to  be  a  separate 
disease,  independent  of  diphtheria,  but  he  considered  that 
it  may  arise  from  diphtheria,  and  Dr.  J.  Solis  Cohen  admits 
that  there  is  no  actual  anatomical  distinction  between  croup 
and  diphtheria,  though  he  contends  that  the  clinical  differ- 


DIPHTHERITIC    CROUP.  265 

ences  are  numerous  and  important.  Dr.  Charles  West,  a 
most  distinguished  writer,  has  come  to  the  conclusion,  which 
he  long  hesitated  to  adopt,  "  that  what  differences  soever 
exist  between  croup  and  diphtheria,  they  must  be  sought 
elsewhere  than  in  the  pathological  changes  observable  in  the 
respiratory  organs."  Nevertheless,  he  adds,  "  If  we  extend 
our  inquiry  beyond  the  mere  changes  wrought  in  the  respir- 
atory organs,  the  differences  between  croup  and  diphtheria 
at  once  become  apparent ;  and  the  affinities  of  the  latter 
disease  are  seen  to  be  to  the  class  of  blood  diseases,  rather 
than  to  that  of  purely  local  inflammations  to  which  croup 
belongs." 

The  Committee  of  the  Royal  Medico-Chirurgical  Society, 
of  London,  came  to  the  conclusion  that  "  these  two  diseases 
are  identical,"  but,  strange  to  say,  the  discussion  on  the 
subject  subject  did  not  lead  the  members  to  harmonious 
conclusions,  for  not  very  many  English  practitioners  would 
say  with  Dr.  Hillier,  "I  can  detect  no  distinction  between 
membranous  croup  and  laryngeal  diphtheria."  Pseudo- 
membranous croup  and  diphtheritic  croup  are  not  identical 
diseases,  but  they  certainly  have  much  in  common,  and,  as 
Dr.  West  puts  it,  "  the  sameness  of  the  anatomical  changes 
produced  by  two  diseases  does  not  suffice  to  establish  their 
identity."  He  adds,  "  The  practitioner  of  midwifery  knows 
that  simple  puerperal  metritis  and  puerperal  fever  are 
diseases  which  differ  widely  in  their  symptoms,  their  course, 
their  danger,  and  the  degree  in  which  they  are  amenable  to 
remedies,  though  in  both,  when  they  terminate  fatally, 
precisely  the  same  alterations  in  the  womb  are  discovered." 

It  is  impossible  to  confound  typical  cases  of  true  croup 
with  typical  cases  of  diphtheritic  croup,  and  only  occasion- 
ally need  there  be  any  doubt  as  to  the  diagnosis.  At 
the  same  time,  I  concede  that  since  the  advent  of  diph- 
theria in  Canada  (1858)  I  have  observed  an  increasing 
disposition  in  pseudo-membranous  croup  to  take  on  a 
kind  of  diphtheritic  aspect,  but  the  same  thing  has  been 
noticed  with  all  diseases  of  the  mouth  and  fauces,  and  one 


266  l'li'ii  nii'ki  nc   croup. 

of  the  very  strongest  proofs  of  the  essential  dissimilarity  of 
the  two  diseases  is  that  given  by  Dr.  Henry  I  Iartshorne:  "A 
table  is  given  in  Meigs  and  Pepper's  treatise  on  the  Diseases 
of  Children,  which  shows  that  after  diphtheria  had,  about 
i860,  become  recognized  as,  at  that  time,  a  new  disease  in 
Philadelphia,  the  mortality  from  it  added,  for  several 
successive  years,  more  than  300  to  the  deaths  in  each  year 
in  that  city,  while  the  deaths  from  croup  continued  to 
number  annually,  as  before,  from  200  to  over  400." 

The  prognosis  is  very  bad.  The  Lancet  Sanitary  Commis- 
sion-Report on  diphtheria  states  that  "  symptoms  of  croupal 
suffocation  soon  supervene  from  the  extension  of  the  diph- 
theritic formation  to  the  air  passages,  and  when  this  is  the 
case,  recovery  is  exceptional."  Dr.  Churchill  says  that  "  when 
the  false  membranes  extend  into  the  larynx  and  trachea  we 
shall  have  croup  with  all  its  danger."  Condie  remarks  that 
"  when  the  disease  extends  to  the  larynx,  it  is  very  frequently 
fatal."  According  to  Greenhow,  "  comparatively  few  persons 
recover  when  diphtheria  extends  downwards  into  the  air 
passages  ;  but  sometimes  moulds  of  the  larynx,  trachea  and 
bronchial  tubes,  to  their  third  or  fourth  division  ;  and  in  a 
case  seen  by  Mr.  Thompson,  of  Launceston,  to  the  fifth 
division,  are  expectorated  with  immediate,  though  too  often 
only  temporary,  relief  to  the  patient,  who  frequently  succumbs 
from  a  renewal  of  the  exudation." 

Dr.  J.  F.  Meigs  says,  "  If  it  extend  into  the  air  passages 
very  soon  after  the  invasion,  it  may  cause  death  within  a  few 
days."  Sir  George  Duncan  Gibb  thinks  that  "  the  prognosis 
of  this  form  (laryngeal  diphtheria)  is  extremely  unfavorable." 
Dr.  Bernhard  Baehr  says  that  "  the  extension  of  the  diph- 
theritic process  to  the  larynx  and  lungs  is  almost  always 
fatal."  Maunsell  affirms  that  "  in  very  acute  cases  the  false 
membrane  will  spread  into  the  larynx,  if  not  early  arrested  ; 
and  in  some  instances  its  formation  seems  to  occur  almost 
simultaneously  in  the  air  passages  and  on  the  pharynx,  the 
croupy  symptoms  appearing  to  co-exist  with  the  appearance 
of  lymph  on  the  fauces ;  such  an  event  we  need  hardly  say 
must  be  almost  necessarily  fatal." 


DIPHTHERITIC    CROUP.  267 

Vogel  states  that  "  in  diphtheritic  croup,  especially  after 
measles,  a  recovery  now  and  then  takes  place,  upon  which 
the  treatment,  as  we  will  see  further  on,  has  no  very  remark- 
able influence.  Where  collapse,  cyanosis  and  an  uncountable 
pulse  have  supervened,  there  speedy  death  may  be  prognos- 
ticated with  certainty."  Oehme  says  that  diphtheria  of 
the  larynx  has  proved,  in  the  greater  number  of  cases,  a 
fatal  disease.  Some  physicians  have  not  hesitated  to  say 
they  have  never  cured  a  case."  Jacobi  says  that  "  diphtheria 
of  the  larynx,  whether  it  be  of  primary  origin  or  the  result 
of  extension  from  the  fauces,  is  nearly  ahvays  fatal.  In 
severe  epidemics  the  mortality  is  95  per  cent. 

In  the  year  i860,  I  wrote  an  essay  on  diphtheritic  croup 
in  which  I  expressed  myself  as  follows  in  regard  to  the 
prognosis:  "But  little  need  be  said  as  to  the  prognosis  of 
this  disease  ;  it  is  bad,  very  bad,  and  I  do  not  believe  that 
more  than  one-half  of  the  cases  recover,  even  under  the  best 
homoeopathic  treatment.  The  cause  of  this  is  evident,  for 
before  the  larynx  is  attacked,  the  patient  has  usually  been 
depressed  and  worn  out  by  the  primary  disease,  and  is  quite 
unfit  to  contend  with  such  a  formidable  foe.  I  find  that  the 
best  plan  is  to  explain  the  state  of  matters  frankly  to  the 
parents  on  being  called  to  the  case,  and  here,  as  in  many 
other  circumstances  of  life,  '  honesty  is  the  best  policy.  " 
The  younger  the  child  the  greater  the  danger  of  diphtheritic 
croup  coming  on  in  the  course  of  diphtheria.  Again,  the 
younger  the  child  the  greater  the  danger  when  laryngeal 
diphtheria  does  make  its  ominous  appearance,  and  this 
increased  danger  arises  from  the  small  size  of  the  larynx  in 
infancy.  Romberg  states  that  "  Richerand  was  the  first  to 
determine  that  the  larynx  and  glottis,  which  in  early  life  are 
very  small,  suddenly  increase  at  the  period  of  puberty,  in 
the  male  sex  in  the  proportion  of  5.10,  in  females  of  5.7. 
Schlemm  has  confirmed  this  observation,  and  has  added  a 
few  details  :  thus  he  found  the  rima  glottidis  of  a  child  of 
twelve  years  one  and  a  half  to  two  lines  longer  than  that  of  a 
child  of  three  years,  and  in  the  latter  it  was  three-quarters  of  a 


268  l'li'ii  i  ii  ii<  1 1  re  croup. 

line  Longer  than  in  a  child  of  nine  months."  When  the 
larynx,  trachea  and  bronchial  tubes  are  lined  with  diphther- 
itic membrane  the  case  is  all  but  hopeless,  though  strange 
cures  take  place,  even  when  the  patient  seems  to  be  in 
extremis^  and  I  particularly  remember  one  notable  case  in 
which,  under  the  influence  of  Kali  bichromicum,  the  patient 
expectorated  a  cast  of  the  larynx,  trachea  and  larger  bron- 
chial tubes  with  immediate  and  permanent  relief. 

In  the  first  volume  of  Marcy  and  I  hint's  Practice,  page 
763,  we  read  that  "  a  persistent  use  of  the  proper  homoeo- 
pathic remedies  will  cure  nearly  all  cases  of  this  malady  " 
(diphtheria),  and  to  this  somewhat  startling  statement  they 
add  that  "  we  have  treated  more  than  200  cases,  including 
many  of  the  malignant  type,  and  our  losses  have  not  been 
one  per  cent."  It  is  not  stated  how  many  of  these  two 
hundred  cases  were  laryngeal  in  their  nature,  though  one 
would  like  very  much  to  know,  but  I  imagine  that  no  experi- 
enced physician  would  make  these  statements  in  connection 
with  diphtheritic  croup. 

Opinions  differ  very  much  as  to  the  value  of  tracheotomy 
in  diphtheritic  croup,  and  till  quite  recently  Dr.  Slade  was 
almost  the  only  writer  of  eminence  who  spoke  favorably  of 
it.  He  says  :  "  Without  going  into  a  history  of  tracheotomy, 
or  a  recapitulation  of  the  arguments  on  the  one  side  or  the 
other,  we  most  unhesitatingly  say  that,  under,  the  circum- 
stances above  mentioned,  this  operation  is  a  resource  which 
we  are  in  duty  bound  to  employ  for  the  safety  of  our  patients, 
and  in  view  of  what  experience  teaches  us  is  otherwise 
certain  death.  It  is  not  by  so  doing  that  we  increase  his 
chances  for  life  solely,  but  in  case  of  an  unfavorable  termi- 
nation we  render  his  last  moments  less  distressing."  Dr. 
Squire,  who  sharply  distinguishes  pseudo-membranous  croup 
from  diphtheritic  croup,  writes  as  follows  :  "  Tracheotomy 
should  be  performed  whenever  the  increasing  recession  of 
the  softer  parts  shows  that  the  cause  of  obstruction  to  the 
entrance  of  air  is  increasing.  In  the  greater  number  of  cases, 
if  the  local  indication  of  the  glottis  and  larynx  do  not  suffice 


DIPHTHERITIC    CROUP.  269 

to  obviate  the  danger,  tracheotomy,  performed  early,  is  much 
more  likely  to  be  successful  than  after  the  use  of  remedies 
that  in  any  way  impair  the  vital  powers.  A  delay  that 
admits  of  secretions  accumulating  in  the  bronchi  is  dangerous, 
and  extension  of  the  disease  to  the  lung  is  the  one  insur- 
mountable obstacle  to  success.  Where  the  effects  of  the 
obstruction  are  more  suddenly  induced,  tracheotomy, 
performed  at  the  very  last  moment  of  apparent  life,  may 
save  it.  No  degree  of  severity  in  the  general  disease  should 
interfere  with  this  means  of  arresting  threatened  death  from 
asphyxia,  unless  the  presence  of  some  other  complication, 
necessarily  fatal,  can  be  demonstrated.  I  recently  saw  a  case 
in  consultation  with  Mr.  Adams,  in  which,  had  it  occurred 
at  the  commencement  of  the  epidemic  instead  of  towards  the 
end,  I  should  have  decided  against  tracheotomy,  concluding 
that  it  must  end  fatally,  although  unconsciousness  had  set 
in  before  commencing  to  operate  ;  the  child,  six  years  old, 
recovered." 

Professor  Rosen,  of  Tubingen,  reports  forty-two  cases  of 
tracheotomy  in  diphtheritic  croup,  with  nineteen  recoveries. 
In  six  of  the  cases  asphyxia  had  advanced  too  far  before  the 
operation,  and  of  the  subsequent  deaths,  one  took  place  from 
pneumonia,  fifteen  days  after,  and  one  from  albuminuria  in 
the  third  week.  Professor  George  Buchanan,  of  Glasgow, 
asserts  that  in  every  eight  cases  of  tracheotomy  performed  on 
children  practically  moribund  from  suffocative  membranous 
effusion  into  the  trachea,  he  has  saved  three.  The  Professor 
reports  50  cases  of  tracheotomy  in  the  British  Medical  Journal 
(1880),  of  which  17  were  classed  as  croup  and  33  as  diph- 
theria, the  latter  including  all  those  forms  in  which  there 
was  a  distinct  deposit  of  white  false  membrane  on  the 
tonsils,  palate,  or  fauces.  Of  the  17  croup  patients,  10  died, 
1  immediately  after  the  operation,  the  others  in  from  3  hours 
to  4  days.  Of  the  33  diphtheria  patients  there  was  a 
mortality  of  21,  1  of  whom  also  died  immediately  after  the 
operation,  the  others  in  from  6  hours  to  13  days. 

Dr.  W.  H.  Day,  who,  like  Dr.  Squire,  holds  that  the  two 


2~0  DIPHTHERITIC    CR01   P. 

diseases  arc  totally  distinct,  yet  reports  the  following 
deeply  interesting  cases  :  "  Two  interesting  cases  of  success- 
ful tracheotomy,  in  the  last  stage  of  diphtheria,  were  brought 
before  the  Clinical  Society  by  Mr.  George  Lawson  and  Mr. 
Pugin  Thornton  (Feb.  28,  1879).  Two  cases  of  diphtheritic 
laryngitis  have  been  recorded,  in  which  recovery  also 
followed  tracheotomy.  The  first  case  was  that  of  a  boy  six 
years  of  age,  who  was  admitted  into  the  Middlesex  Hospital 
under  the  care  of  Dr.  Coupland,  May  30,  1880.  The  success- 
ful issue  was  owing  to  the  operation  having  been  performed 
at  an  early  period  of  the  disease  before  much  false  membrane 
had  formed. 

"The  second  case  was  also  that  of  a  boy  seven  years  of 
age,  who  was  admitted  into  the  Children's  Hospital  under 
the  care  of  Dr.  Gee,  on  September  15,  1879.  Recovery 
followed  quickly,  notwithstanding  the  extreme  dyspnoea  at 
the  time  of  operation,  and  the  large  quantity  of  membranous 
casts  expelled  through  the  tube  afterwards." 

Steiner  thinks  that  "  when  the  larynx  becomes  implicated 
the  various  external  and  internal  remedies,  which  have 
already  been  referred  to  under  the  diseases  of  the  larynx* 
such  as  emetics,  must  be  employed,  and,  failing  any  benefit 
from  these,  there  remains  only  the  operation  of  tracheotomy." 
Dr.  Jacobi,  the  most  persistent  advocate  of  the  unity  of 
croup  and  diphtheria  on  this  continent,  writes  as  follows  : 
"  In  regard  to  tracheotomy,  that  last  resort  in  croup,  I 
cannot  refrain  from  stating  that,  in  proportion  to  the  increas- 
ing severity  of  the  diphtheritic  epidemics,  the  results  of 
tracheotomy  in  my  hands  and  in  those  of  others,  have  grown 
worse  and  worse.  Of  sixty-seven  tracheotomies  which  I 
published  twelve  years  ago,  twenty  per  cent,  recovered  ; 
about  two  hundred  tracheotomies  performed  by  me  since 
that  time  brought  down  the  percentage  of  recoveries  to 
such  a  low  figure  that  only  the  utter  impossibility  of 
witnessing  a  child's  dying  from  asphyxia  has  goaded  me  on 
to  the  performance  of  tracheotomy.  I  here 'add  that  I  do 
not  wish  it  to  be    inferred  that   I   have  changed  my  views 


DIPHTHERITIC     CROUP.  271 

concerning  the  indications  for  the  operation  of  tracheotomy, 
as  Boehme  seems  to  believe.  On  the  contrary,  in  spite  of 
numerous  ill  successes,  I  hold  to  the  principle  that  where 
there  is  danger  of  suffocation  through  stenosis  of  the  larynx, 
there  is  the  indication  for  tracheotomy.  Where  there  is  no 
stenosis,  I  am  glad  not  to  operate.  The  results  are  not  so 
bad,  after  all,  when  we  remember  that  only  such  cases  are 
operated  upon  which  would  be  sure  to  die,  if  the  operation 
were  not  performed." 

One  would  like  to  know  how  many  of  the  patients  treated 
by  Buchanan,  Squire  and  others  had  true  diphtheria  with 
blood-poisoning,  and  how  many  had  a  purely  local  laryngitis 
with  exudation,  but  lacking  the  blood-poisoning  which  is 
almost  of  the  essence  of  diphtheria.  On  this  point  the 
remarks  of  Dr.  Alfred  Meadows*  are  of  the  greatest  value, 
the  more  so  as  that  excellent  writer  believes  croup  and 
diphtheria  to  be  identical  diseases.  After  stating  that 
Trousseau  believes  that  half  the  operations  performed  will 
be  successful,  always  provided  that  tracheotomy  takes  place 
when  the  chances  of  cure  are  possible,  he  adds :  "  This 
restriction  is  important ;  for  if  the  diphtheritic  infection  is 
thoroughly  rooted  in  the  system,  if  the  skin,  and  particularly 
the  cavities  of  the  nose,  are  invaded  by  this  special  phleg- 
masia, as  is  often  the  case  in  France  ;  if  the  quickness  of  the 
pulse,  delirium  and  prostration  indicate  a  profound  poison  ; 
and  if  the  danger  is  rather  in  the  general  state  than  in  the 
local  lesion  of  the  larynx  or  trachea,  certainly  the  operation 
should  not  be  tried,  for  it  is  invariably  fatal."  Dr.  Meadows 
further  adds,  "  when,  however,  the  local  lesion  constitutes 
the  principal  danger  of  the  disease,  no  matter  to  what  degree 
asphyxia  has  arrived,  even  when  the  child  seems  to  have 
only  a  few  moments  to  live,  tracheotomy  very  often  succeeds" 
— and  this  "  local  lesion  "  is  correctly  styled  pseudo-membra- 
nous croup. 

Dr.  Morrell  Mackenzie  thinks  that  "  considering  the 
enormous  mortality  of  laryngeal  diphtheria,  even  the  most 
unfavorable  figures  prove  that  in  such  cases  tracheotomy  is 


DIPHTHERITIC    CROUP. 

not  only  justifiable,  but  that  it  is  a  positive  duty ;"  yet 
Mackenzie  gives  a  table  of  "operations  for  croup,"  in  the 
Hdpital  des  Enfants  Malades,  showing  that  whereas  in  1X51 

the  cures  were  1  in  2.21,  in  1S75  the  cures  were  1  in  4.76 
Mackenzie  gives  a  similar  table  for  the  Hdpital  Saintc 
Eugenie,  showing  that  while  the  cures  in  1854  were  1  in  4.50, 
in  iS/6the  proportion  of  cures  was  only  I  in  8.31.  M. 
Mazard  attributes  this  stead}'  increase  in  the  mortality,  after 
tracheotomy,  "  partly  to  the  progressive  extension  of  the 
operation  to  more  and  more  hopeless  cases,  and  partly  to 
the  more  malignant  character  of  the  disease  in  Paris  during 
recent  years  ;"  but  I  incline  to  attribute  it  to  the  fact  that 
in  the  earlier  years  true  croup  was  chiefly  present,  while  in 
the  later  years  there  was  much  more  diphtheria. 

Oertel  writes  :  "  According  to  the  notes  of  Professor  von 
Nussbaum,  which  he  has  most  kindly  communicated  to  me, 
of  twelve  undoubtedly  diphtheritic  children,  whose  ages 
varied  between  three  and  four,  and  on  whom  he  had 
performed  tracheotomy,  all  died  ;  and  only  two  older  ones, 
whose  ages  were  twelve  and  fourteen,  survived,  but  in  them 
the  whole  course  of  the  disease  had  shown  itself  much  more 
favorable."  Dr.  Helmuth  remarks  :  "  The  results  after  the 
operation  of  tracheotomy  in  croup  are  not  very  satisfactory, 
and  in  diphtheria  they  are,  as  far  as  my  observation,  reading 
and  experience  extend,  still  less  so.  I  can  call  to  mind  but 
four  cases  in  which  the  operation  has  been  performed  in 
diphtheria,  one  of  which  is  said  to  have  proved  successful. 
None  of  these  cases,  however,  occurring  in  my  own  practice, 
and  circumstances  occurring  which  have  prevented  actual 
inquiry  in  reference  to  the  minutiae  of  each,  I  am  not 
prepared  to  offer  any  remarks  upon  them.  But  in  the  cases 
which  I  have  treated,  and  which  have  succumbed  to  the 
diphtheritic  poison,  I  have  not  witnessed  one  which  would 
justify  the  interference  of  the  surgeon."  Dr.  A.  L.  Voss  of 
New  York  says  :  "  It  is  worthy  of  remark  that  I  have  not 
heard  of  a  successful  operation  in  New  York  during  the  year 
1859,  famous    for   diphtheria.      Tracheotomy   is   a   dernier 


DIPHTHERITIC    CROUP.  273 

resort  in  diphtheria.  I  have  no  confidence  in  it  in  this 
disease.  Diphtheria  is  an  affection  of  which  the  local  lesion 
is  the  least  important  part.  Its  erratic  nature,  its  proneness 
to  reappear  upon  a  neighboring  or  remote  surface,  argues 
very  strongly  against  the  promise  of  success  by  local  means 
alone.  If  you  remove  the  plastic  deposit  from  the  trachea  by 
a  surgical  operation,  a  few  hours  later  will  be  apt  to  reveal 
symptoms  of  a  like  formation  within  the  larynx  or  the 
bronchi.  Possibly  the  operation  may  be  serviceable  in  croup, 
but  not  in  diphtheria." 

In  almost  all  the  statistics  adduced  to  prove  the  value  of 
tracheotomy  in  diphtheritic  croup,  the  comparatively 
manageable  pseudo-membranous  croup  is  mingled  with  the 
very  unmanageable  diphtheritic  croup,  so  that  little  reliance 
can  be  placed  on  them.  For  example,  Dr.  Morell  Mackenzie 
writes  :  "  At  the  Hospital  for  Sick  Children  in  the  twelve 
years,  1864  to  1876,  sixty  cases  of  croup  and  diphtheria  were 
operated  on.  Of  these,  thirteen,  or  21.6  per  cent.,  were 
successful."  One  wants  to  know  how  many  of  these  cases 
were  croup,  and  how  many  were  diphtheria,  for  the  mortality 
is  much  more  than  trebled  by  the  presence  of  the  diphtheritic 
blood-poisoning,  and  no  experienced  physician  expects  to 
save  21  out  of  every  100  cases  of  genuine  diphtheritic  croup. 
And  even  when  some  little  attempt  is  made  to  discriminate 
between  the  two  diseases,  the  diagnosis  is  so  superficial  that 
it  commands  no  respect.  Thus  of  the  50  tracheotomy  cases 
of  Buchanan's,  already  alluded  to,  17  were  classed  as  croup 
and  33  as  diphtheria,"  the  latter  including  all  those  forms  in 
which  there  was  a  distinct  deposit  of  white  false  membrane 
on  the  tonsils,  palate  and  fauces."  Of  the  17  croup  cases  10 
died,  of  the  33  so-called  diphtheritic  ones  21  died — not  a 
very  great  difference  in  the  mortality.  And  it  is  not 
sufficient  for  diagnostic  purposes  to  tell  us  that  there  was  a 
"  distinct  deposit  of  white  false  membrane  on  the  tonsils, 
palate  or  fauces,"  for  that  is  often  seen  in  pseudo-membranous 
croup,  but  one  wants  to  know  the  history  of  these  cases, 
whether  or  not  diphtheritic  blood-poisoning  was  present,  and 


iMi'in  !M'i:i  I  [C    CROUP. 

till  that  is  done,  I  will  ponder  the  words  of  Vogcl,  "  We 
really  have  few  diphtheritic,  but  mostly  genuine  fibrinous 
croup  patients." 

Commenting  on  von  Nussbaum's  cases,  already  alluded  to, 
Oertel  writes  as  follows,  and  his  weighty  words  must 
command  the  respectful  attention  of  all  physicians  of 
experience  :  "If  now,  figures  are  to  be  found  in  literature 
which  furnish  niuch  more  favorable  statistics  of  tracheotomy 
in  diphtheria,  these  data  cannot  be  considered  as  trustworthy 
so  long  as  the  boundaries  between  croup  and  diphtheria  are 
not  precisely  defined  ;  in  the  cases  referred  to  above  the 
diagnosis  of  diphtheria  was  established  beyond  a  doubt.  It 
is  very  evident  that  the  issue  of  such  an  operation  should  be 
wholly  different  if  the  case  is  one  of  a  simple  exudative 
process  in  the  respiratory  mucous  membrane,  following  a 
local  inflammation  of  high  degree,  and  not  one  in  which  the 
local  trouble  is  the  primary  localization  of  a  general 
infectious  disease." 

In  diphtheritic  croup,  as  a  very  general  thing,  the 
condition  of  the  patient  forbids  any  surgical  interference 
whatever,  and  it  is  only  in  rare  cases  like  those  of  Squire  and 
von  Nussbaum  that  it  should  be  even  thought  of.  In  croup 
you  have  to  do  with  a  disease  which  is  local,  or  at  least  very 
largely  so,  and  here  tracheotomy  is  admissible  in  certain 
cases,  but  in  diphtheritic  croup  you  have  to  do  with  a  patient 
who,  in  addition  to  a  severe  local  disease,  is  suffering  from  a 
violent  blood-poisoning,,  and  here  the  chances  of  success,  or 
even  of  palliation  are,  save  in  very  rare  cases,  illusory  in  the 
extreme. 

The  bed-chamber  must  be  lofty  and  well-ventilated.  The 
air  must  be  both  warm  and  moist,  and  draughts  must  be 
carefully  avoided.  The  only  prophylactic  treatment  which 
is  of  any  avail  is  the  prompt  removal  of  children  from  the 
infected  locality.  That  must  be  done  at  once,  for  here  no 
chemical  agent  is  of  any  use,  and  some  of  them,  notably 
chloride  of  lime,  positively  invite  the  disease  to  the  larynx. 
The  food  must  be  nourishing  and  liquid.      Milk  very  slightly 


DIPHTHERITIC    CROUP.  275 

thickened  with  arrow-root  is  excellent,  and  well  made  beef- 
tea  is  always  in  place.  But  I  have  had  the  best  results  from 
oyster-soup,  giving  only  the  thin  part.  Both  English  and 
German  writers  give  stimulants  in  large  doses,  but  I  have 
rarely  seen  any  good  from  them,  and  it  seems  to  me  that  the 
dose  of  which  Oertel  speaks — an  ounce  or  an  ounce  and  a 
half  of  Cognac  in  twenty-four  hours  to  children  only  three 
or  four  years  old — is  excessively  large.  In  the  matter  of 
after-treatment,  it  is  of  importance  to  see  that  the  child  does 
not  over-exert  the  organ  of  voice.  Rest,  nourishing  food, 
fresh  air  are  indispensable,  and,  when  seasonable,  sea-air  is  the 
best  of  all  restoratives. 

Physicians  of  our  school  differ  very  much  as  to  the  value 
of  Kali  Bichromicum  in  laryngeal  diphtheria.  Dr.  Ludlam 
thinks  that  it  is  almost  specific  to  the  diphtheritic  membranes 
found  upon  the  respiratory  epithelial  surface,  and  this  is 
endorsed  by  Drs.  Marcy  and  Hunt,  while  Dr.  Lord,  of 
Chicago,  emphatically  says  that  it  is  the  remedy.  Dr.  A.  E. 
Small,  of  Chicago,  says  ;  "  I  have  found  the  3d  attenuation 
of  this  remedy  of  the  greatest  value  in  diphtheritic  croup 
when  administered  early  after  the  manifestation  of  the 
difficulty.  I  have  given  it  when  the  following  symptoms 
were  present  :  hoarse,  croupy  cough  ;  sore  throat  ;  the 
appearance  of  livid  patches,  indicative  of  false  membrane,  at 
the  posterior  of  the  fauces  ;  great  prostration  and  laborious 
breathing."  On  the  other  hand,  Dr.  Hughes,  of  London, 
has  used  it  "  without  the  least  benefit,"  and  in  a  later  work, 
he  adds  that  u[\n  laryngeal  diphtheria  it  does  all  that 
medicine  can  do,  which,  unhappily,  is  not  much,"  and  Dr. 
Laurie  seems  to  consider  it  a  kind  of  forlorn  hope  to  be 
given  if  Bromine  should  fail  ;  the  Bromine  have  been  given 
when  Iodine  failed.  Dr.  Bernhard  Baehr,  while  admitting 
that  "  the  symptoms  of  this  drug  undoubtedly  point  to  its 
use  in  diphtheria,  and  assign  to  it  an  important  rank  among 
the  remedies  for  this  disease,"  remarks  that  "  striking 
therapeutic  results  have  not  yet  been  attained  with  it."  In 
this  matter  I  entirely  and  cordially  agree  with  Dr.  Ludlam, 


276  l  M  I'll  III  l  RITIC    CRI  'i   P. 

and  have  no  hesitation  in  assigning  to  Bichromate  of  potash 
the  first  place  in  the  brigade  of  remedies  with  which  wc 
combat  diphtheritic  croup.  Dr.  Ludlam's  remarks  are 
worthy  of  the  most  careful  perusal  : 

"i.  This  remedy  seems  especially  appropriate  to  pseudo- 
membranous lesions  of  a  diphtheritic  nature  affecting  the 
respirator)'  mucous  surfaces,  as  the  nares,  the  superior 
portion  of  the  pharynx,  the  larynx,  the  trachea,  and  the 
bronchial  tubes,  even   down  to   their  ultimate  ramifications. 

"  2.  Where  the  deposit  is  of  firmer  texture,  more  apt  to  be 
developed  into  casts  which  are  cartilaginous  or  pearly  in 
in  appearance,  elastic,  fibrinous,  and  more  securely  attached 
to  the  subjacent  integument. 

"  3.  It  is  indicated  in  all  those  cases  where  a  transfer  of 
the  local  disorder  to  the  larynx  or  trachea  impends,  as  shown 
by  soreness  of  the  larynx  when  pressed  upon  from  before 
backwards,  aphonia,  croupy  inspiration  or  cough,  and  a 
desire  on  the  part  of  the  patient  to  lie  with  the  head  thrown 
backwards  in  order  to  open  the  glottis. 

•'  4.  It  may  also  be  given  with  excellent  results  in  case  the 
tonsils  are  almost  or  quite  enveloped  by  a  thick  and  well- 
organized  deposit,  and  in  which  at  the  same  time  the  patient 
has  an  almost  incessant  cough. 

"  5.  Also  where,  with  the  foregoing  symptoms,  there  is 
an  evident  tendency  to  ulceration  and  deposit  upon  remote 
mucous  membranes,  as,  for  example,  those  of  the  uterine 
system.  In  my  own  experience,  the  Bichromate  is  almost  a 
specific  to  diphtheritic  formations  upon  the  free  uterine,  and 
to  those  found  upon  the  respiratory  epithelial  surfaces. 

"  6.  Since  in  all  these  cases  the  putrid  symptoms  are  less 
marked  than  in  the  pharyngeal  and  alimentary  diphtheria, 
you  should  take  the  hint  to  cease  the  employment  of 
Bichromate  when  these  symptoms  ensue.  The  Iodine  of 
arsenic.  Nitric  acid,  or  Carbo-vegetabilis  are  much  more 
decidedly  indicated  for  the  relief  of  such  a  condition.  " 

The  diphtheritic  croup  in  which  this  remedy  is  indicated, 
is  generally  an   extension  from  the  fauces,  simply  because 


DIPHTHERITIC    CROUP.  277 

that  is  the  usual  development  of  the  disease,  but  it  is  the 
first  remedy  to  be  thought  of  when  the  disease  originates  in 
the  larynx  in  the  first  place,  and  extends  thence  to  the 
fauces.  The  pseudo-membrane  lining  the  fauces  and 
extending  to  the  air  passages  is  whitish-yellow  or  of  an 
ashy-grey  hue,  and  the  fetor  is  quite  marked.  The  croupous 
cough  occurs  in  paroxysms,  especially  worse  from  two  to 
three  o'clock  in  the  morning,  and  this  cough  occasionally 
expels  viscid  mucus,  which  may  be  drawn  out  into  long 
strings,  and  the  same  tough  and  stringy  discharge  occasion- 
ally appears  in  the  nostrils,  forming  masses  of  partially-dried 
mucus,  or  there  may  be  a  thick,  dark,  bloody  discharge  from 
the  nostrils.  The  tongue  is  raw,  red  and  shining,  or  covered 
with  a  brownish-yellow  coating,  and  the  parotid  and  sub- 
maxillary glands  are  distinctly  swollen.  Upon  deglutition, 
the  pain  shoots  up  the  ear  and  to  the  neck  of  the  affected 
side.     The  patient  is  very  weak,  and  has  a  cachectic  look. 

Dr.  Lord,  of  Chicago,  advises  the  administration  of  this 
remedy  by  inhalation.  The  following  is  an  extract  from  his 
report  of  a  very  severe  case  in  which  the  remedy  caused  an 
aggravation,  even  when  given  in  moderate  doses :  "  When 
the  Bichromate  was  given  at  intervals  of  an  hour  or  more, 
the  patient  uniformly  got  worse.  The  cough  was  almost 
constant,  except  in  the  night  when  asleep.  It  ran  up  from 
a  slight  hacking  to  suffocation,  which  was  only  prevented  by 
a  means  which  I  have  purposely  omitted  to  mention  that  I 
might  direct  your  attention  more  particularly  to  it.  After 
the  twentieth  day,  when  the  cough  became  dry,  and  the 
respiration  whistling,  and  when  suffocation  seemed  immi- 
nent, inhalations  of  the  Bichromate  were  used  with  prompt 
relief ;  of  course  it  was  only  temporary,  but  it  was  a  respite. 
But  for  it  death  must  have  ensued.  It  did  not  fail  in  a 
single  instance  of  easing  the  breathing  and  loosening  the 
cough,  and  ejection  of  membrane  or  large  quantities  of 
stringy  mucus  followed.  The  method  was  simple.  Two  or 
three  grains  of  Bichr.  2  were  put  into  a  smail  tin  teapot  and 
half  a  teacup  of  hot  water  poured  on.     The  vapor  passing 


-■;S  hii'iri  in  u ti  il  r. 

from  the  spout  was  inhaled.  I  do  not  think  that  any 
medicines  given  in  this  case  but  the  Arsenic  and  Bichromate 
had  any  good  effect.  I  was  so  well  satisfied  of  this  that  in 
all  subsequent  cases  1  have  trusted  entirely  to  the  Bichro- 
mate as  the  specific  remedy,  and  have  had  no  reason  to 
repent  it.  Other  remedies  may  be  required,  but  that  is  the 
remedy." — {Illinois  State  Horn.  Trans.,  1862.) 

Dr.  Hughes  says:  "I  think  that  Dr.  Neidhardt's  sugges- 
tion is  very  good,  that  it  is  necessary  to  attack  the  poison  in 
the  blood,  even  while,  by  the  medicines  specifically  affecting 
the  air  passages,  you  are  combating  its  dangerous  local 
manifestation.  He  usually  administers  the  Bichromate  of 
potash  1  1st  trit.)  in  alternation  with  his  Chloride  of  lime. 
He  has  recorded  two  instances  in  which  this  treatment 
proved  successful/'  To  me,  cases  in  w  J  rich  alternated  remedies 
were  used  are  as  if  they  never  had  been  recorded.  This 
remedy  seems  to  act  best  in  the  2d  or  3d  decimal  tritura- 
tions, a  small  powder  in  half  a  cup  of  water,  of  which  a 
teaspoonful  is  to  be  given  every  hour  or  oftener.  The 
remedy  should  be  given  by  inhalation  at  the  same  time. 

All  who  have  used  Iodine  consider  that  it  is  best  indicated 
in  the  early  stage  of  diphtheria  when  much  glandular 
irritation  is  present,  and  when  the  disease  threatens  to  attack 
the  larynx.  Dr.  Laurie  thinks  that  "  when  in  addition  to 
the  formation  of  specks  or  patches  of  exudation  of  greater 
or  less  extent,  with  sore  throat,  enlargement  of  the  tonsils 
or  glands  of  the  neck,  disinclination  for  food,  difficulty  of 
breathing,  cough  and  alteration  of  the  voice  ensue,  the  admin- 
istration of  Iodine  should  be  at  once  resorted  to."  Dr.  Kidd 
says  that  the  essential  pathogenetic  action  of  Iodine  comes 
the  nearest  of  all  our  remedies  to  the  essential  character- 
istics of  diphtheria  in  its  constitutional  and  local  manifesta- 
tions. Dr.  F.  G.  Snelling  says  that  its  internal  use  should 
be  in  frequent  repetition,  and  accordingly  he  advises  that 
ten  drops  of  the  first  decimal  dilution  of  Iodine  be  added  to 
half  a  cup  of  pure  cold  water,  a  teaspoonful  to  be  given 
every  20  or  30  minutes.    "  To  produce  a  prompt  and  perfect 


DIPHTHERITIC    CROUP.  279 

influence,  Dr.  Kidd  thinks  it  best  to  administer  it,  '  similia 
similibus  curantur]  in  the  mode  of  entrance  of  the  disease 
itself — viz.,  by  inhalation  ;  or  the  Iodine,  in  substance  or  in 
tincture,  may  be  placed  in  an  open  vessel  near  the  patient, 
as  it  is  thus  slowly  evaporated,  and  mixes  with  the  air  in  a 
highly  divided  and  quickly  acting  form." — [Snelling.)  Dr. 
McNeil,  the  best  writer  on  the  homoeopathic  therapeutics  of 
diphtheria  that  has  yet  appeared,  says  that,,  it  is  only  in 
rare  cases  that  Iodine  will  ever  be  indicated  " — and  I  entirely 
agree  with  him. 

Dr.  Helmuth  supplies  us  with  the  following  valuable 
details  as  to  the  best  mode  of  administration  by  inhalation  : 
"When  the  disease  is  not  arrested  by  these  medicines- 
(Caustic  ammonia  and  Protiodide  of  mercury) — and  there 
is  the  slightest  appearance  of  cough — I  order  the  inhalation 
of  the  vapor  of  Iodine,  and  that  medicine  in  the  second 
dilution,  in  water,  every  two  hours.  The  inhalation  is 
conducted  as  follows :  a  small  teapot  is  filled  with  boiling 
water,  and  a  teaspoonful  of  pure  tincture  of  Iodine  poured 
therein ;  the  patient  takes  the  spout  of  the  vessel  in  the 
mouth,  and  the  head  being  covered  with  a  towel,  a  few 
inspirations  are  made.  This  method  is  resorted  to  when 
there  is  no  inhaling  glass  convenient,  and  it  will  be  found  to 
answer  the  purpose  exceedingly  well.  The  inhalation  may 
be  repeated  three  times  during  the  day.  There  can  be  no 
doubt  of  the  efficacy  of  this  method  of  treatment — viz. : 
Iodine,  internally  and  topically,  by  inhalation,  in  severe  diph- 
theritis,  even  after  the  cough  has  commenced.  I  have 
witnessed  its  efficacy  several  times,  and  would  have  others 
test  it  in  similar  cases." 

Dr.  Peters  says  that  Bromine  causes  inflammation  of  a 
transudative  character  in  the  larynx  and  trachea,  with 
commencing  formation  of  false  membranes ;  violent  inflam- 
mation of  the  fauces  and  oesophagus,  and  coating  of  them 
with  plastic  lymph  ;  intense  inflammation  of  the  larynx  and 
trachea,  with  exudation  of  plastic  lymph  in  such  abundance 
as  quite  to  block  up  the  air  passages.     He  adds  that  it  is 


hll'ii  I  HERlTlC    CR<  >UP. 

rather  more  applicable  to  the  Inflammatory  cases  tending 
towards  the  larynx  with  sharp  fever  at  the  outset.  Dr.  J. 
1'.  Dake  gives  the  following  indications:  "Soreness  and 
smarting  in  the  throat;  ptyalism ;  hoarseness;  rough,  dry 
cough  ;  sensation  of  contraction  in  the  windpipe  ;  fluent 
coryza;  also  nasal  obstruction;  epistaxis;  earache;  alternate 
chills  and  heat;  violent  inflammation  of  the  mucous  mem- 
brane of  the  fauces,  oesophagus,  also  of  the  larynx  and 
trachea  ;  these  parts  are  covered  with  a  coagulable  lymph 
which  obstructs  almost  entirely  the  air  passage.  A  dingy, 
brownish,  granular,  firmly-adhering  exudation  over  the 
mucous  membranes  of  the  oesophagus."  Dr.  Trinks  recom- 
mends it  in  severe  inflammation  of  the  fauces  and  oesophagus 
covering  them  with  plastic  lymph,  also  in  severe  inflamma- 
tion of  the  larynx  and  trachea,  with  exudation  of  plastic 
lymph  nearly  closing  these  organs.  Dr.  Laurie  recommends 
Bromine  to  be  used  in  laryngeal  diphtheria  when  Iodine 
has  failed.  Dr.  McNeil  advises  Bromine  "  when  the  disease 
commences  in  the  larynx  and  comes  up  into  the  fauces,  and 
in  some  cases  in  which  it  runs  down  into  the  larynx  and 
produces  a  croupy  cough,  with  much  rattling  of  mucus." 
Dr.  W.  C.  Dake  observes  that  "generally  we  have  not  had 
satisfactory  results  from  its  use,"  and  Dr.  Hughes  says  that 
"  Bromine  is  the  only  rival  of  Kali  bichromicum  when  diph- 
theria invades  the  larynx,"  yet  his  personal  experience  has 
not  been  favorable.  Dr.  Charles  Neidhard,  of  Philadelphia, 
says,  "  I  have  been  consulted  in  four  or  five  cases  of  diph- 
theritic croup  where  Bromine  was  freely  administered,  in 
large  and  small  doses,  without  any  effect.  They  all  died. 
In  one  or  two  of  my  own  cases,  it  was  also  administered 
without  benefit.  It  would  seem  that  Bromine  has  not  much 
effect  in  diphtheritic  croup,  nor  in  diphtheria  generally." 
Personally,  I  have  made  little  use  of  Bromine  in  this  disease, 
partly  because,  as  Dr.  Bayes  remarks,  it  is  "  an  unmanageable 
medicine,"  and  partly  because  I  seldom  saw  grounds  for  its 
administration.  I  conclude  that,  though  it  is  occasionally 
indicated  in  pseudo-membranous  croup,  it  is  not  in  homceo- 


DIPHTHERITIC    CROUP.  281 

pathic  rapport  with  diphtheria  in  any  of  its  manifold  phases, 
great  care  should  be  taken  to  preserve  this  remedy  and  the 
dilutions  should  be  made  each  time  it  is  used.  "A  gargle 
made  with  one  drop  of  pure  Bromine  to  six  ounces  of  water 
has  proved  serviceable  in  diphtheria  threatening  to  invade 
the  larynx.  It  makes  the  false  membrane  brittle  and  brings 
it  away,  while  it  stimulates  the  subjacent  mucous  membrane." 
— (Bayes.) 

According  to  Dr.  Peters,  Ammonium  causticum  causes 
reddening  of  the  nasal  mucous  membrane  which  is  coated 
with  an  albuminous  layer  ;  reddening  of  the  posterior  surface 
of  the  epiglottis  and  of  the  entrance  into  the  rima  glottidis, 
which  are  covered  with  a  false  membrane  ;  great  redness  of 
the  whole  trachea  and  bronchi,  which  are  coated  here  and 
there  with  uiembranous  patches.  He  adds  that  it  may  be 
used  in  diphtheria  when  the  prostration  and  exhaustion  are 
very  great,  and  the  disease  tends  to  extend  down  into  the 
larynx,  trachea  and  air  passages.  Dr.  J.  P.  Dake  states  that 
he  has  used  this  remedy  with  gratifying  results,  by  nasal 
inhalation,  but  has  not  found  benefit  from  the  internal 
administration  of  the  drug.  Dr.  McNeil  observes  that  as 
this  remedy  has  been  used  but  little,  we  need  further 
clinical  provings  (cures?)  to  clearly  establish  its  province  in 
diphtheria. 

Dr.  F.  X.  Spranger  of  Detroit  reports  the  following  cure 
in  the  American  Homoeopathic  Observer,  Vol.  I:  "Among 
the  many  cases  that  I  have  successfully  treated  with  this 
medicine,  I  shall  mention  but  one.  It  was  a  case  of  croupous 
diphtheria ;  a  servant  girl  20  years  of  age  ;  corpulent, 
plethoric  constitution.  When  first  called  to  see  her  she  had 
a  croupous  cough,  which  threatened  suffocation  every 
moment  On  examination,  found  the  lower  part  of  the 
pharynx  covered  with  a  white  pseudo-membrane  extending 
down  as  far  as  could  be  seen.  Patient  was  in  the  greatest 
agony,  frequently  jumping  out  of  bed  and  gasping  for  breath. 
I  dropped  15  drops  of  Ammonium  causticum  into  a  tumbler- 
ful   of  water,  one-half-teaspoonful  to  be  given  every  hour. 


282  DIPHTHERITIC    I  ROUP. 

Left  the  patient  soon  afterwards,  aboul  6  o'clock  r.  M. 
(The  patient  lived  in  the  country.)  While  taking  the  first 
few  doses  she  nearly  strangled,  deglutition  being  so  difficult. 
Soon  afterwards  she  began  to  get  easier.  Next  morning.  I 
found  the  patient  sitting  up  in  bed,  breathing  freely.  Had 
taken  some  broth  ;  deglutition  was  very  easy  ;  the  pseudo- 
membrane  had  entire:!)-  disappeared,  and  the  patient  was 
discharged  cured  the  next  day  afterwards."  Commenting 
on  this.  Dr.  Oehme  remarks  that  "  though  there  is  but  one 
cure  on  record,  yet  we  are  forced  to  consider  Ammon.  caust. 
a  great  remedy  in  diphtheritis." 

Excellent  observers  of  the  dominant  school  bear  unwitting 
testimony  to  the  homceopathicity  of  this,  remedy  to  the 
diphtheritic  process.  Thus  Trendelenburg  found  that  it  was 
capable  of  causing  the  formation  of  false  membranes  in  the 
trachea,  and  Dr.  H.  C.  Wood  confirms  the  observation. 
Delafond  called  "  croup  "  into  existence  by  means  of 
Ammonia,  and  Oertel  constantly  insists  on  there  being  "  no 
actual  difference  between  croup  as  it  ordinarily  occurs,  and 
that  excited  in  the  windpipe  of  a  rabbit  by  means  of 
Ammonia.  The  color  and  texture,  the  physical,  chemical, 
and  histological  characteristics  are  identical." 

Dr.  Hughes  advises  Apis  mellifica  in  the  '  croupal '  form 
of  diphtheria  "  when  a  lower  type  of  inflammation  (as  shown 
by  a  mere  purple  color  of  the  parts)  and  much  greater 
oedema  are  the  first  signs  of  the  supervention  of  the  croupous 
upon  the  catarrhal  form  of  "diphtheria,  or  of  its  primary 
onset."  Dr.  Oehme,  whose  work  on  the  therapeutics  of 
diphtheria  is  simply  invaluable,  remarks:  "Because  one 
physician  has  found  Apis  of  no  benefit  in  diphtheritis  of  the 
larynx,  it  does  not  follow  that  it  will  be  thus  in  all  cases,  as 
we  cannot  expect  one  drug  to  be  the  only  remedy  for  this 
disease."  And  he  adds  :  "  If  we  take  into  account  the 
following  symptoms  :  "  Voice  grew  hoarse  ;  breathing  and 
swallowing  very  difficult  ;  difficulty  of  swallowing  not  caused 
by  the  swelling  of  the  throat,  but  by  the  irritation  of  the 
epiglottis;  sensation  as   of  a    rapid    swelling    of    the    lining 


DIPHTHERITIC    CROUP.  283 

membrane  of  the  air-passages  ;  rough  voice  ;  speaking  painful ; 
hoarse  cough  ;  intense  sensation  of  suffocation,  could  bear 
nothing  about  the  throat  ;  hurried  difficult  respiration  ; 
labored  inspiration  as  in  croup,  etc.;"  we  see  no  reason  why 
it  should  be  neglected  in  these  cases."  In  confirmation 
of  these  indications,  I  report  the  following  case  in  the 
American  Observer,  Vol.  XV:  "On  November  20th,  1877, 
I  was  called  to  W.  S.,  a  boy  aged,  nine  years.  He  had 
flying  chills,  followed  by  great  heat  with  debility  ;  pulse  108  ; 
temperature  in  the  axilla,  I02|°.  The  throat  was  very  red 
with  difficult  deglutition  and  severe  pains,  felt  even  when 
not  swallowing.  I  prescribed  Apis  mel.,  5th  dec.  trit.,  one 
grain  in  eight  teaspoonfuls  of  water,  a  teaspoonful  every 
hour.  At  the  same  time  I  ordered  the  Grauvogel  gargle, 
composed  of  equal  quantities  of  spirits  of  wine  and  water, 
every  two  hours  during  the  day,  together  with  a  diet  exclu- 
sively of  milk.  For  two  days  the  situation  remained  almost 
unchanged,  but  on  the  morning  of  November  23d,  a  thick, 
yellowish,  diphtheritic  exudation  covered  the  uvula,  tonsils 
and  pharynx,  while  the  tongue  had  a  thick,  yellowish  coating 
with  inflamed  papillae  and  a  high  degree  of  fetor.  The 
diphtheritic  membrane  was  of  the  consistence  of  clotted 
cream,  of  a  yellowish  color,  closely  adherent  to  the  subjacent 
mucous  membrane,  and  of  a  fetid  smell.  The  fever  increased, 
and  the  morning  temperature  averaged  io2|°  and  the 
evening  103^°.  No  solid  food  could  be  taken,  and  small 
quantities  of  milk  formed  the  sole  nourishment.  The 
Granvogel  gargle  was  continued,  though  it  caused  intense 
pain  each  time  it  was  used.  The  weakness  and  prostration 
increased  to  an  alarming  extent,  and  the  characteristic  bluish 
tint  of  the  face  was  distinclty  marked.  The  nostrils  now 
became  affected,  and  poured  out  a  thin,  fetid  sanies.  On 
November  28th  the  membrane  extended  lower  down  the 
pharynx,  and  on  the  following  day  the  hoarse  and  croaking 
voice  announced  that  the  pharynx  was  at  last  involved,  and 
this  was  confirmed  by  the  stethoscope.  Apis  was  now  given 
in  grain  doses  of  the  5th  dec.  trit.,  dry  on  the  tongue,  every 


-\S.|  hiPli  PHERITIC    CR<  'i  r. 

two  hours.  On  November  30th  the  voice  was  entirely 
suppressed,  with  a  hoarse  and  difficult  cough,  accompanied 
by  the  expectoration  of  small  quantities  of  membrane.  On 
December  1st  the  uvula  began  to  shed  its  membrane,  and 
during-  the  five  following  daws  an  astonishing  amount  of 
membrane  was  parti)'  expectorated,  partly  vomited.  Not- 
withstanding the  very  serious  state  of  the  larynx,  no  change 
was  made  in  the  remedy,  except  that  the  (irauvogel  gargle 
was  discontinued.  On  December  6th  the  tonsils  and  pharynx- 
were  almost  clear  of  membrane,  the  voice  returned,  the 
laryngeal  cough  became  softer,  and  the  patient — very  wan 
and  prostrate — entered  on  convalescence.  Throughout  the 
entire  progress  of  the  disease,  the  patient  presented  Guern- 
sey's key-note  symptom,  "Puffiness  about  the  eyes.1'  Dismissed 
on  December  8th,  no  remedy  but  Apis  having  been  used. 
Since  this  case  was  reported,  I  have  attended  three  others, 
strikingly  similar  to  it,  in  which  the  same  results  were 
obtained  from  Apis. 

Oehme  gives  the  following  excellent  indications  for 
Lachesis :  ;'  The  subjective  symptom  much  severer  than  the 
objective  ;  violent  pain  in  the  throat ;  extremely  painful  and 
difficult  sivalloiving ;  sensation  of  a  foreign  body  in  the 
throat,  with  stinging  extending  into  the  ear ;  urgency  to 
swallow,  and  desire  to  hawk  up  something,  with  choking 
spells ;  dislike  to  have  the  throat  touched  ;  pale,  redness  of 
the  fauces  ;  exudate  begins  or  is  zvorse  on  the  left  side  ;  voice 
weak  and  hoarse  ;  aphonia;  cough  causes  pain  ;  fector  oris  ; 
fetid  discharge  from  mouth  and  nose ;  violent  prostration, 
even  before  the  exudation  ;  lassitude  ;  weakness  ;  pulse  weak, 
small;  perspiration  cold,  clammy;  somnolency;  delirium; 
symptoms  worse  after  sleep." 

Dr.  William  Morgan  says  of  this  remedy :  "  This  remark- 
able production  of  the  animal  kingdom  may  always  be 
trusted  as  an  auxiliary  in  removing  that  distressing  and 
painful  sensation  of  strangulation  and  suffocation,  as  if  a 
cord  were  tied  tightly  round  the  throat,  which  marks  certain 
forms  of   scarlet  fever,  the    phlegmonous    sore    throat    and 


DIPHTHERITIC    CROUP.  285 

diphtheria;  indeed,  I  have  never  found  Lachesis  fail  in  this 
important  symptom ;"  but  as  Dr.  McNeil  well  remarks, 
"  Lachesis  is  one  of  our  most  important  remedies  in  both 
the  laryngeal  and  septic  forms,"  adding  that  "  the  indica- 
tions are  so  clear  that  mistakes  are  inexcusable." 

Dr.  Ludlam,  of  Chicago,  was  the  first  to  point  out,  on  the 
authority  of  M.  Laboulbene,  that  the  constitutional  action 
of  Tartar  emetic  will  produce  a  pseudo-membrane  upon  the 
buccal,  the  laryngeal  and  the  tracheal  mucous  surfaces. 
"The  indications  which,  in  my  own  experience,  more 
frequently  require  this  remedy  in  diphtheria,  are  sudden 
swelling  of  the  cervical  glands  and  tonsils,  occurring  in 
scrofulous  children,  who  are  predisposed  to  catarrhal  or 
asthmatic  affections;  occlusion  of  the  larynx  or  lower 
respiratory  channels  by  excess  of  mucus,  or  of  a  feebly 
organized  plasma,  with  cough,  dysphagia,  difficulty  of 
breathing,  gasping  (which  compels  the  patient  to  sit  upright 
or  to  seek  the  open  air) ;  inclination  to  retching  and 
vomiting,  obstinate  vomiting  of  a  tenacious  mucus  without 
any  considerable  thirst ;  small  circular  patches,  like  small- 
pox pustules,  in  and  upon  the  mouth  and  tongue  ;  and  also 
for  evidences,  of  closure  of  the  pulmonary  air  vesicles  by 
solidification  of  effused  serum  (hepatization).  It  will  some- 
times serve  a  good  purpose  by  promoting  diaphoresis,  and  in 
exceptional  cases  will  drive  out  the  eruption,  to  the  great 
relief  of  internal  mucous  surfaces.  I  reccommend  you  not 
to  overlook  the  claims  of  this  remedy  in  certain  forms  and 
varieties  of  the  diphtheritic  lesion.  In  particular,  it  seems 
applicable  to  many  cases  of  diphtheria  in  which  the  abnormal 
throat  and  chest  symptoms  derive  their  chief  characteristics 
from  a  prevalent  influenza,  or  from  an  inherent  predisposi- 
tion on  the  part  of  the  patient  to  catarrhal  disorders  of  the 
respiratory  mucous  membrane." — {Ludlam).  The  writer  has 
used  Tartar  emetic  to  a  considerable  extent,  but  thinks  that 
it  is  more  appropriate  for  pseudo-diphtheria  than  in  the 
genuine  disease.  As  to  the  dose,  a  grain  of  the  3d  or  4th 
decimal  trituration   may  be  dissolved  in  half  a  cup  of  water 


DIPHTHERI1  [C    CRI  >UP. 

and  a  I  :n  every  one  or  two  hours,  or  a  small 

powder  of  the  ;th  or  6th  trituration  may  be  given  dry  on 
the  tongue  every  two  hours. 

If  the  diphtheritic  laryngitis  should  be  a  primary  disease, 
good  results  may  be  expected  from  Aconite,  provided  it  is 
given   promptly  and   in   m  s,  certainly  not  higher 

than  the  2d  dec.  dilution,  but  if  it  does  not  check  the 
disease  at  once,  some  other  remedy  should  be  substituted 
for  it. 

Sir  George  Duncan  Gibb  recommends  Sanguinaria  "as  an 
emetic  in  the  croupal  form  of  diphtheria."  My  own  experi- 
ence is  that  when  the  membrane  is  diffluent  this  remedy  is 
effective,  but  not  when  the  membrane  is  tough  and  closely 
adherent  to  the  mucous  membrane. 

Dr.  W.  C.  Dake,  who  has  had  excellent  results  in  this 
disease,  seems  to  consider  that  Spongia  rivals  Kali  bichro- 
micum.  He  advises  "Spongia  for  paleness  of  the  face  and 
anxious  features  ;  stitches  in  the  throat,  great  dryness  of  the 
larynx,  with  short,  barking  cough ;  difficult  breathing,  as 
from  constriction  of  the  larynx  and  trachea  ;  pain  in  larynx 
when  pressing  upon  it ;  hoarseness ;  dry  cough,  worse  in  the 
evening  and  toward  morning  from  a  tickling  in  the  wind- 
pipe." Dr.  Dake  gives  Spongia  in  the  1st  decimal  dilution, 
a  dose  every  hour. 

Aphorisms. 

i.  Diphtheritic  croup  is  the  development  upon  the  larynx 
and  trachea  of  the  characteristic  membrane  of  diphtheria, 
and,  as  a  general  rule,  the  disease  originates  by  extension 
from  the  pharynx,  it  being  a  very  rare  thing  to  find  it  origi- 
nate in  the  larynx. 

2.  In  some  epidemics,  laryngeal  diphtheria  is  so  common 
as  to  give  the  characteristic  features  and  name  to  the  disease, 
while  in  other  epidemics  it  is  very  rare. 

3.  It  is  more  common  in  low,  swampy  lands,  and  on  the 
margin  of  bodies  of  water,  than  on  high  and  rolling  land. 


DIPHTHERITIC    CROUP.  287 

4.  The  proportion  of  cases  of  laryngeal  diphtheria,  as 
compared  with  the  whole  number  of  cases  of  diphtheria, 
varies  from  15  to  67  per  cent.,  and  the  mortality  in  cases  of 
diphtheria  in  which  the  larynx  is  attacked,  varies  from  40  to 
95  per  cent. 

5.  Many  of  the  croup  epidemics  of  the  eighteenth  century, 
in  England,  Scotland  and  on  the  North  American  Continent, 
were  epidemics  of  what  would  now  be  called  diphtheritic 
croup. 

6.  When  death  takes  place  in  diphtheria  within  a  week,  it 
is  usually  by  extension  of  the  disease  to  the  larynx  ;  when 
death  takes  place  later,  it  is  almost  always  the  result  of 
asthenia. 

7.  The  characteristic  membrane  is  of  various  textures, 
sometimes  as  soft  as  thick  cream,  sometimes  like  moist  kid- 
leather. 

8.  The  membrane  may  extend  from  the  epiglottis  to  the 
minute  ramifications  of  the  bronchial  tubes,  and  as  it 
descends  it  becomes  less  and  less  consistent. 

9.  The  prognosis  is  very  unfavorable,  even  under  enlight- 
ened homoeopathic  treatment,  and  the  danger  largely  arises 
from  the  fact  that  the  patient  is  suffering  from  a  serious 
blood  poisoning  in  addition  to  the  local  disease,  and  also 
that  when  the  laryngeal  complication  appears  the  patient  is 
already  exhausted  by  the  primary  disease. 

10.  The  younger  the  child  the  greater  the  danger  of 
diphtheritic  croup  coming  on  in  the  course  of  diphtheria, 
and  the  younger  the  child  the  greater  the  danger  when  it 
does  make  its  appearance. 

11.  As  to  therapeutics,  Kali  bichromicum  heads  the 
column,  closely  followed  by  Apis  mellifica,  Lachesis  and 
Ammonium  causticum.  .Of  less  importance,  but  still  deserv- 
ing of  careful  study,  are  Spongia,  Iodine,  Aconite,  Sanguin- 
aria,  Bromine  and  Tartar  emetic. 

12.  While  tracheotomy    is  often  the  last  reserve — and  a 


288  m;i  \  i  i\ai    CROUP. 

successful  one  too,  if  not  too  long  delayed — in  true  croup,  it 
is  seldom  admissible  in  diphtheritic  croup. 

[3.  The  physician  may  sometimes  be  tempted  to  use  an 
emetic  for  the  purpose  of  removing  the  membrane  from  the 

larynx,  but  the  relief  is,  at  best,  only  temporary,  and  the 
irritation  of  the  emetic  action  often  intensifies  the  disease 
and  hastens  the  fatal  issue. 


CHAPTER    X. 


Scarlatinal  Croup. 


Scarlatinal  croup  is  a  phase  of  disease  to  which  exceed- 
ingly little  reference  is  made  in  the  medical  writings  of  any 
school,  and  yet,  though  it  is  fortunately  infrequent,  it 
requires  skill  and  promptitude  more  than  any  other  compli- 
cation of  scarlatina.  Objection  may  be  made  to  any  separate 
chapter  on  this  subject,  as  the  malady  forms  one  phase  of  a 
general  disease,  and  hence  should  be  described  with  that 
disease.  However,  on  account  of  the  dangerous  nature  of 
the  complaint,  and  also  in  view  of  the  fact  that  no  essay  on 
the  subject  is  contained  in  the  literature  of  our  school,  I 
have  thought  it  best  to  present  the  following  chapter. 

Scarlatinal  croup,  then,  is  a  secondary  inflammation  of  the 
larynx,  occurring  almost  exclusively  in  the  most  malignant 
forms  of  scarlatina  when  the  whole  mass  of  fluids  has  been 
vitiated.  It  may  originate  by  extension  of  the  inflammatory 
irritation  from  the  pharynx,  though  it  sometimes  appears 
when  the  pharynx  is  but  little  affected. 

Scarlatinal  croup  is  not  a  common  phase  of  disease,  for  in 
the  words  of  Professor  Trousseau,  ''scarlatina  has  no  liking 


SCARLATINA!,   CROUP.  289 

for  the  larynx."  It  may  appear  in  patients  of  any  age,  but 
it  seems  to  me  to  be  most  frequent  between  the  ages  of  four 
and  eight.  I  have  never  noted  it  in  infants,  and  all  my 
patients,  except  two,  were  under  ten  years  of  age.  Both 
sexes  seem  to  be  alike  liable  to  the  disease. 

In  many  instances,  scarlatinal  croup  originates  by  extension 
of  the  well-known  sore  throat  of  scarlatina,  but  in  most  of 
the  cases  I  have  observed,  exposure  to  cold  was  the  exciting 
cause.  The  illustrious  Sydenham — doubtless  encouraged  by 
the  success  of  his  cool  regimen  in  small-pox — thought  that 
scarlatina  patients  ought  to  get  up  every  day,  even  when  the 
eruption  was  at  its  height.  But  scarlatina  patients  are  much 
more  susceptible  to  cold  than  small-pox  patients ;  in  fact, 
above  all  the  eruptive  fevers  scarlatina  needs  to  be  guarded 
against  cold.  All  my  fatal  cases  originated  in  exposure  to 
cold.  One  wilful  nurse  stripped  a  little  patient  to  the  skin 
at  the  height  of  scarlatina,  and  carried  it  about  in  a  fireless 
kitchen  for  the  purpose  of  "  cooling  the  fever."  Scarlatinal 
croup  came  on,  and  the  case  was  hopeless  when  next  seen. 
Another  woman  kept  her  little  one,  sick  of  scarlatina,  in  a 
well-warmed  room  during  the  day,  but  every  night  removed 
it  to  her  own  fireless  bedroom  situated  at  the  extremity  of  a 
long,  rambling  farm-house,  and  this,  too,  during  the  month 
of  February,  1868 — the  coldest  part  of  the  most  severe 
Winter  I  ever  saw  in  Canada.  Here,  too,  the  larynx  was 
attacked  with  fatal  result.  In  January,  1870,  among  other 
scarlatina  patients  I  had  one  who  made  a  fair  recovery, 
though  the  type  of  disease  was  malignant.  After  I  dismissed 
the  case,  the  mother  kept  the  cradle  exposed  to  the  cold  air 
blowing  in  through  an  imperfectly-closed  window,  and  fatal 
scarlatinal  croup  was  the  result. 

Croup  may  come  on  during  the  early  stages  of  scarlatina, 
or  it  maybe  one  of  sequelae.  It  usually  comes  on  insidiously 
and,  amidst  the  anxiety  of  a  serious  disease,  it  may  be 
unnoticed  for  a  time.  There  is  at  first  a  very  slight 
hoarseness,  with  muffled  cough  and  a  mingled  gurgling 
and    trilling   sound   in    the    larynx  ;    after    the    cough    the 


2QO  \!'.1.\  I  l\  \l     CR01    I'. 

gurgling  disappears  for  a  time.  These  symptoms  arc 
frequently  ;  I   by  a  slight  chill,  followed  by  heat  of 

skin  and  accelerated  pulse,  but  this  may  easily  pass  without 
remark'.  At  first  there  is  no  dyspnoea,  but  soon  marked 
diflficulty.of  breathin  on,  and  the  dyspnoea  indicates 

the  degree  of  danger  present,  which  is  usually  in  precise 
proportion  to  this  symptom.  The  patient  involuntarily  rises 
in  bed  and  stretches  out  the  head,  while  the  eyes  have  an 
anxious  and  haggard  expression.  The  cheeks  are  flushed 
and  the  eyes  sufl  At  this  stage  the  tissues  of  the  neck 

become  swollen  and  infiltrated,  and  this,  of  course,  increases 
the  dyspnoea  and  hoarseness.  There  are  no  intermissions  in 
this  variety  of  croup;  there  is,  however,  a  very  slight  remission 
in  the  morning,  and  usually  a  very  severe  exacerbation 
during  the  hours  immediately  before  and  after  midnight. 
There  is,  in  a  majority  of  cases,  a  steady,  onward  march  of 
the  disease,  the  dyspnoea  increases,  the  respiration  becomes 
more  stertorous,  the  cough,  after  becoming  harsher,  is  finally 
suppressed,  the  strength  fails,  wild  terrors  and  the  ever- 
present  feeling  of  suffocation  prevent  sleep,  and  finally  the 
patient  dies,  comatose  or  convulsed.  But,  on  the  other 
hand,  under  the  influence  of  a  well  chosen  remedy,  the 
dyspncea  may  decrease,  the  cough  may  become  less  frequent 
and  less  hoarse,  quantities  of  membrane  may  be  vomited  or 
swallowed,  and  the  sleep  of  the  patient  then  announces  that 
the  pressing  danger  has  passed  away.  In  another  group  of 
cases  croup  comes  on  suddenly  and  almost  without  warning. 
At  one  visit  you  leave  your  scarlatina  patient  doing  well, 
and,  when  you  next  see  him,  the  case  is  hopeless  or  almost 
hopeless. 

The  progress  of  this  disease  is  very  rapid,  even  more  so 
than  pseudo-membranous  croup.  Most  of  the  fatal  cases  I 
have  seen  lived  only  from  two  to  three  days. 

The  false  membrane  of-  scarlatinal  croup  is  thinner,  softer 
and  less  adherent  than  the  membrane  of  pseudo-membranous 
croup  ;  at  the  same  time,  it  is  less  uniformly  spread  over  the 
affected   part.      It    is    grayish  or    of    a  yellow  color,  and  is 


SCARLATINAL   CROUP.  291 

frequently  associated  with  small  quantities  of  pus,  or  it  may 
be  granular  in  texture  and  friable  in  consistence.  But  little 
fibrin  enters  into  its  composition  and  it  rapidly  decomposes. 
The  subjacent  mucous  membrane  is  softened  and  of  a  dark 
purplish  hue,  while  the  sub-mucous  areolar  tissue  is  infiltrated; 
in  fact,  all  the  pathological  appearances  point  to  the  locali- 
zation of  a  degenerated  blood  disease.  Professor  Wood 
remarks  that  the  membrane  seldom  extends,  unless  in 
small  quantities,  below  the  larynx. 

In  the  great  majority  of  cases  the  diagnosis  is  plain,  for 
the  history  of  the  case  must  be  investigated  as  well  as  the 
present  state  of  the  patient.  The  only  cases  in  which  there 
is  reasonable  ground  for  doubt  are  those  which  Trousseau 
denominates  defaced  scarlatina  (scarlatine  fraste),  in  which 
some  of  the  most  important  symptoms  of  the  malady  are 
suppressed  or  non-existent.  When,  for  example,  there  is  no 
appearance  of  the  characteristic  eruption,  but  instead  you 
have  severe  sore  throat,  with  deposition  of  false  membrane, 
it  would  be  difficult  to  decide  whether  the  disease  was 
scarlatina  or  diphtheria,  for  a  fetid  smell  exhales  from  the 
mouth  and  nostrils,  the  pulse  is  small  and  fluttering,  the  skin  is 
pale  and  the  temperature  of  the  body  is  notably  low.  In 
such  cases  one  of  the  best  diagnostics  would  be  the  period 
at  which  albuminuria  appeared,  for,  as  is  well  known,  in 
diphtheria  it  appears  early  in  the  .disease,  while  in  scarlatina 
it  does  not  make  its  appearance  till  the  case  is  far  advanced. 
But  in  about  one-fifth  of  the  whole  number  of  diphtheritic 
cases  there  is  no  albuminuria,  and  then  the  physician  must 
look  for  other  diagnostic  points.  There  are  two  sources  of 
fallacy  in  scarlatinal  croup,  to  which  I  would  direct  special 
attention.  The  first  of  these  will  be  found  in  the  phenomena 
presented  by  a  certain  number  of  cases  of  scarlatina  in 
which  a  quantity  of  matter  in  the  posterior  nares  and  upper 
part  of  the  pharynx  forms  a  mucous  rhoncus  which  closely 
simulates  croup.  But  here  auscultation  clears  up  the 
difficulty  at  once  by  showing  that  the  larynx  is  not  involved. 
In  another  set  of  cases  the  tumefaction  of  the  neck  is  so 


M;i  ATI  V\l     i   Knur. 

great  that  it  causes  stertorous  respiration,  which  bears  a 
certain  resemblance  to  croup.  Here,  too,  auscultation  is  of 
some  value,  but  a  better  diagnostic  is  the  absence  of  the 
hoarse  COUgh. 

I  look  upon  scarlatinal  croup  as  being  one  of  the  most 
fatal  of  all  the  varieties  of  croup.  It  is  more  dangerous 
when  it  comes  on  at  an  advanced  period  of  the  course  of 
scarlatina — say  the  tenth  or  twelfth  day — than  when  it 
attacks  at  an  early  period.  It  is  very  dangerous  when  it 
arises  by  extension  from  the  pharynx,  but  it  is  still  more 
dangerous  when  it  appears  as  an  intercurrent  inflammation, 
the  result  of  exposure  to  cold.  Tumefaction  of  the  neck,  if 
of  great  extent,  is  an  unfavorable  sign,  and  when  coma  or 
delirium  appear  there  is  little  room  for  hope.  Much,  very 
much,  depends  upon  prompt  recognition  of  the  disease  and 
upon  equally  prompt  therapeutics. 

But  one  of  the  weak  points  about  our  knowledge  of 
scarlatinal  croup  is  that  we  have  no  well-defined  treatment 
such  as  we  possess  in  so  many  affections,  and  I  regret  that  I 
can  give  but  a  few  fragmentary  hints  derived  entirely  from 
personal  experience.  Here  I  cannot  refrain  from  again 
pointing  out  the  necessity  of  opposing  the  very  beginnings  of 
disease.     "  Obsta  principiis." 

When  recognized  at  an  early  period,  Aconite  is  indicated 
in  a  majority  of  cases,  but  it  should  be  given  in  the  form 
tincture,  as  dilutions  are  merely  a  waste  of  invaluable  time. 
I  have  great  confidence  in  Sanguinaria  and  the  confidence 
is  derived  from  the  fact  that  since  I  have  used  this  remedy 
I  have  been  much  more  successful  than  formerly. 

A  homely  proverb  says  that  "  an  ounce  of  prevention  is 
worth  a  pound  of  cure,"  and  I  am  strougly  of  the  opinion 
that  inunctions  of  olive  oil  are  preventive  of  scarlatinal 
croup  as  well  as  of  many  of  the  complications  and  sequehe 
of  scarlatina.  I  use  them  in  every  case  of  scarlatina  as 
follows :  I  direct  one  arm  of  the  patient  to  be  bathed 
lightly  with  tepid  water,  and  then  quickly  dried,  and,  when 
thoroughly  dry  a  small  quantity  of  pure  olive  oil  is  rubbed 


SCARLATINAL   CROUP.  29,3 

over  the  limb.  Then  the  other  arm  is  treated  in  the  same 
manner,  and  so  on,  till  the  entire  person  has  been  bathed 
and  anointed.  As  a  result  the  temperature  is  lowered,  the 
irritation  of  the  skin  is  allayed,  and  the  liability  to  take  cold 
is  almost  wholly  removed. 

Aphorisms. 

1.  Scarlatinal  croup,  fortunately  not  a  common  disease, 
appears  in  children  of  any  age,  and  both  sexes  seem  to  be 
alike  liable  to  it. 

2.  The  disease  may  originate  by  extension  from  the 
pharynx,  but  it  is  most  commonly  caused  by  exposure  to 
cold. 

3.  Scarlatinal  croup  is  one  of  the  most  rapidly  fatal  of  all 
the  forms  of  croup,  and  it  is  more  dangerous  when  it  appears 
late  in  the  course  of  scarlatina  than  when  it  comes  on  at  an 
early  period. 

4.  The  leading  remedies  are  Aconite,  Sanguinaria  and 
Kali  bichromicum,  and  inunction  with  olive  oil  is  the  best 
prophylactic. 


CHAPTER   XI. 


Tracheitis. 


Is  there  such  a  disease  as  tracheitis?  To  read  one  series 
of  medical  authors,  one  would  quite  believe  that  there  was 
such  a  disease,  distinctly  marked  and  well  known,  and  as 
thoroughly  understood  as  any  malady  in  the  nosological 
tables.  To  read  another  set  of  writers — quite  as  eminent 
and  quite  as  well  informed  as  the  other — one  would  conclude 
from  their  brief  remarks,  and  still  more  from  the  silence  of 
some  of  them,  that  while  all  other  parts  of  the  human 
organism  may  be  the  victim  of  what  the  lamented  Constan- 
tine  Hering  used  to  call  "an  itis"  the  trachea  was  the  one 
happy  spot  which  never  knows  what  inflammation  means. 
-By  one  group  of  writers  tracheitis  is  considered  to  be  synon- 
omous  with  croup.  Sir  Thomas  Watson — the  Macau  lay  of 
British  Medicine — speaks  of  "another  of  Dr.  Cullen's  species 
of  cynanche — viz. :  cynanche  trachealis — tracheitis — croup  ;" 
and  Hasse — perhaps  the  most  eminent  of  the  Swiss  patholo- 
gists— considers  tracheitis  and  croup  to  be  interchangeable 
terms.  When  such  curious  errors  are  made  by  the  great 
lights  of  the  school  of  medicine  which  has  most  zealously 
cultivated  pathology  and  pathological  anatomy,  one  does 
not  wonder  to  see  the  author  of  the  Hydropathic  Encyclo- 
paedia follow  in  their  wake. 

George  B.  Wood,  M.  D.,  formerly  Professor  of  Theory  and 
Practice  of  Medicine  in  the  University  of  Pennsylvania — 
certainly  the  greatest  writer  on  disease  that  this  continent 
has  yet  produced — offers  the  following  remarks:  "In  a 
pathological  account  of  the  several  portions  of  the  air 
passages,  it  might  be  thought  that  the  trachea  would  receive 


TRACHEITIS.  29$ 

a  separate  consideration  ;  but  it  is  very  seldom  exclusively 
affected,  offers  no  symptoms  when  inflamed  which  are  not 
observed  in  other  localities,  and  requires  absolutely  nothing 
peculiar  in  its  treatment.  The  nomenclature  which  gives 
the  title  of  tracheitis  to  croup  is  founded  on  a  false  assump- 
tion in  relation  to  the  special  seat  of  that  complaint.  It  is 
true  that  the  trachea  is  generally  affected  in  croup ;  but  it  is 
almost  never  exclusively  affected ;  nor  are  the  peculiar 
features  of  the  disease  essentially  connected  with  that  part 
of  the  respiratory  passages.  The  symptoms  and  treatment 
of  tracheitis  are  almost  always  merged  in  those  of  laryngitis 
and  bronchitis."  The  fact  that  the  trachea  is  very  seldom 
exclusively  affected,  is  not  a  good  reason  for  passing  over 
the  disease  altogether,  as  the  same  remark  might  be  made 
respecting  some  other  parts  of  the  organism  ;  and  it  is 
difficult  to  understand  what  is  meant  by  the  remark  that  it 
"offers  no  symptoms  when  inflamed  which  are  not  observed 
in  other  localities,"  seeing  that  tracheitis  is  quite  different 
from  the  inflammations  of  kindred  regions,  and  that  the 
same  remark  might  be  made  regarding  almost  any  local 
inflammation — especially  the  inflammations  of  the  enceph- 
alon.  The  remark  that  the  disease  "  requires  absolutely 
nothing  peculiar  in  its  treatment/'  is  quite  in  place  with 
therapeutics  who  are  groping  in  the  twilight  of  the  so-called 
"  physiological  medicine,"  but  it  is  repudiated  by  those  who 
heal  the  sick  in  accordance  with  a  great  law  of  nature. 

Tracheitis,  then,  may  be  defined  to  be  an  inflammation  of 
the  mucous  membrane  of  the  windpipe,  usually  arising  from 
exposure  to  cold,  and  characterized  by  a  croup-like  cough 
with  profuse  secretion  of  mucus.  This  inflammation  may 
be  either  primary  or  secondary  ;  in  the  latter  class  it  reaches 
the  trachea  by  extension  from  the  larynx.  Although  the 
inflammation  may  extend  downwards  from  the  larynx  to  the 
trachea,  it  is  rare  to  find  it  extending  upwards  from  the 
trachea  to  the  larynx,  and  a  similar  remark  may  be  made  as 
to  the  relation  between  tracheitis  and  bronchitis.  Indeed, 
it  seems  to  be  a  general  law  that  inflammations  of  the  respir- 
atory organs  extend  downwards. 


tk  \«  ni.i  ris. 

Tracheitis  is  usually  a  catarrhal  inflammation,  though  it  is 
sometimes  sthenic.  Very  seldom  has  the  writer  seen  it  of  a 
pseudo-membranous  nature,  though  it  is  well  to  bear  in 
mind  Rindfleisch's  caution:  "the  development  of  a  false 
membrane  is  connected  in  the  closest  manner  with  the 
catarrhal  state,  and  constitutes  the  anatomical  acme  of  the 
morbid  process."  It  is,  perhaps,  never  diphtheritic,  though 
diphtheria  may  extend  from  the  larynx  to  the  trachea. 
This  disease  has  no  separate  history,  for,  following  Cullen's 
vicious  nosology,  it  has  almost  invariably  been  confounded 
with  croup,  from  which  it  differs  in  many  important  partic- 
ulars. Almost  all  writers  who  have  recognized  the  existence 
of  tracheitis  have  remarked  its  infrequency,  but  a  more 
careful  examination,  and  especially  the  more  frequent  use  of 
the  stethoscope,  would  have  proved  that  it  is  quite  frequently 
met  with.  Boys  are  more  subject  to  it  than  girls,  and  it  is 
more  frequent  in  fall  and  spring  than  at  other  seasons  of  the 
year. 

Exposure  to  draughts  of  cold  air  is  the  most  usual  cause 
of  tracheitis,  but  in  children  wet  feet  will  usually  be  found 
to  be  the  starting  point  of  the  disease.  Children  who  have 
been  confined  to  the  house  during  the  winter  season  are 
very  apt  to  be  attacked  with  laryngeal  and  tracheal  inflam- 
mations when  they  first  go  out  in  spring,  and  nearly  all  the 
writer's  cases  occurred  in  March  and  April.  Previous  attacks 
form  an  undoubted  predisposing  cause  of  the  disease,  and 
the  susceptibility  is  increased  with  each  attack. 

Tracheitis  is  usually  preceded  by  premonitory  symptoms 
resembling  those  of  catarrh.  The  patient  has  more  or  less 
chilliness — not  the  distinctly  marked  chill  of  a  sthenic 
inflammation,  but  a  creeping,  disagreeable  feeling  of 
chilliness,  intermingled  with  heat — and  this  chilliness  is 
followed  in  increased  heat  of  the  surface,  with  marked 
lassitude  and  loss  of  appetite.  Felix  von  Niemeyer  points 
out  that  this  chilliness  is  rarely  confined  to  a  single  rigor, 
thus  forming  an  important  point  of  distinction  between  the 
onset  of  a  catarrhal  and  of  an  inflammatory  fever.     Shiver- 


TRACHEITIS.  297 

ings  recur  with  every  little  alteration  of  temperature,  or  on 
such  slight  exposure  as  changing  the  linen.  A  dull  frontal 
headache  is  present,  with  throbbing  of  the  temporal  arteries, 
bruised  pain  in  the  limbs,  and  pain  in  the  joints,  increased 
by  pressure  or  motion. 

Sometimes  there  is  only  a  slight  irritation  in  the  trachea,  or 
a  kind  of  tickling  which  provokes  a  short,  hacking  cough,  but 
usually  the  cough  is  violent  and  paroxysmal.  This  cough  is 
of  three  tolerably  distinct  varieties,  according  as  the  inflam- 
mation is  confined  to  the  windpipe,  or,  in  addition,  touches 
the  larynx  or  the  bronchi.  When  the  inflammation  is 
confined  to  the  trachea,  the  cough  is  at  first  dry  and 
spasmodic  and  of  frequent  recurrence,  later  there  is  an 
expectoration  of  thick,  ropy  mucus ;  when  the  larynx  is 
implicated,  the  cough  is  hoarse,  metallic  and  convulsive, 
while  the  breathing  is  loud  and  wheezing ;  when  the  disease 
invades  the  bronchi,  the  cough  is  dry  at  the  commencement, 
but  becomes  looser  in  two  or  three  days,  with  sputa  of  frothy 
mucus  mixed  with  pus  and  sometimes  streaked  with  blood. 
Prosser  James  remarks  that  "  the  voice  will  be  unaffected  so 
long  as  the  larynx  is  not  also  involved  ;  "  but  I  have  noted 
that  even  when  the  larynx  is  not  affected  the  voice  has  a 
ringing  and  metallic  sound  which  is  quite  distinct  from  the 
hoarse  clangor  of  true  croup.  There  is  no  real  dyspnoea  in 
tracheitis,  owing  to  the  large  calibre  of  the  affected  organ  as 
compared  with  that  of  the  larynx  or  bronchi.  The  expec- 
toration in  simple  tracheitis  is  more  copious  than  in 
laryngitis,  but  much  less  abundant  than  when  the  bronchi 
are  involved  in  the  inflammatory  action.  Prosser  James 
says  that  occasionally  the  expectoration  appears  in  rings  ; 
I  have  never  observed  this  phenomenon.  As  might  be 
expected  from  the  anatomical  relations  of  the  trachea  and 
oesophagus,  there  is  considerable  dysphagia  accompanied  by 
a  feeling  of  constriction  ;  sometimes  this  is  so  considerable 
that  the  ingesta  returns  by  the  nostrils  and  mouth.  The 
cause  of  this  is  obvious,  for,  as  the  lower  extremity  of  the 
trachea  is  necessarily  fixed,  it  follows  that  the  upper  extrem- 


298  TRACHEITIS. 

ity  moves  upwards  with  the  larynx  in  swallowing,  and, 
therefore,  if  the  tracheal  mucous  membrane  is  inflamed,  pain 
must  be  felt  during  deglutition.  Morell  Mackenzie  denies 
the  occurrence  of  dysphagia  in  the  course  of  tracheitis,  on 
the  ground  that  though  he  has  watched  for  the  symptom 
he  has  never  yet  met  with  it,  but  a  very  slight  acquaintance 
with  the  rules  of  evidence  shows  the  futility  of  such  an 
argument.  In  severe  cases  there  is  considerable  swelling  of 
the  neck,  but  this  is  rare.  The  characteristic  pain  of 
tracheitis  is  a  burning,  stinging  pain,  aggravated  by  pressure 
and  motion,  and  felt  much  lower  down  than  the  pain  of 
laryngitis  or  croup. 

Like  croup,  tracheitis  usually  developes  itself  during  the 
night.  The  patient  has  usually  been  suffering  from  what 
was  assumed  to  be  a  slight  cold,  and  has  retired  to  bed, 
apparently  in  good  health,  but  in  the  night  he  awakes  with 
the  spasmodic^cough  and  the  loud  and  ringing  voice,  while 
at  the  same  time  the  skin  is  hot  and  the  face  flushed. 
During  the  day  the  malady  intermits,  but  on  the  approach 
of  evening  the  paroxysm  reappears  in  an  aggravated  form 
and  with  increased  fever.  The  cough  becomes  more 
frequent  and  more  annoying,  and  the  thick,  ropy  mucus  can 
be  distinctly  heard  rattling  in  the  windpipe.  Should  the 
disease  be  controlled  by  proper  treatment,  the  cough 
diminishes  and  the  characteristic  burning  and  stinging  pain 
disappears;  the  voice  resumes  its  natural  tones,  and  the 
fever  subsides,  leaving  behind  it  languor  and  malaise.  If 
the  patient  is  old  enough,  free  expectoration  takes  place, 
but  in  a  majority  of  cases  the  secretions  are  brought  up  to 
the  pharynx  and  then  swallowed.  Relapses  are  quite 
frequent,  and  the  patient  is  ever  after  subject  to  the  disease. 
In  cases  which  terminate  unfavorably,  the  bronchial  tubes 
become  involved,  the  cough  increases  in  frequency,  the 
expectoration  becomes  purulent  and  profuse,  the  appetite 
fails,  and  the  body  emaciates,  till  the  child  sinks  into  its 
grave  with  a  group  of  symptoms  closely  resembling  those  of 
phthisis  pulmonalis. 


TRACHEITIS.  .  299 

Tracheitis  of  a  sthenic  nature  lasts  from  five  to  seven  days, 
and  is  more  easily  cured  and  is  less  likely  to  become  chronic 
than  if  it  were  catarrhal  in  its  nature.  It  is  also  less  likely 
to  invade  the  bronchi.  Pseudo-membranous  and  diphtheritic 
tracheitis  are  rarely  found,  save  as  parts  of  one  general 
disease  from  which  the  patient  has  but  little  chance  of 
recovery.  Catarrhal  tracheitis  is  the  most  common  variety, 
and  so  far  as  my  experience  goes,  is  comparatively 
easy  of  cure,  but  it  often  recurs  and  is  apt  to  become 
chronic.  In  a  great  majority  of  cases  it  extends  to  the 
bronchial  tubes,  and  this  bronchitis  is  apt  to  become 
chronic.  Chronic  tracheitis  may  last  for  many  months,  and, 
as  in  one  case  which  I  observed,  may  linger  for  a  year, 
getting  alternately  better  and  worse,  till  at  last  recovery 
takes  place.  Such  cases  may  be  complicated  with  chronic 
bronchitis,  when,  as  has  been  remarked,  the  case  will  strongly 
resemble  consumption. 

Usually  the  thermometer  shows  an  elevation  of  tempera- 
ture, say  from  one  to  two  degrees  above  health,  at  the 
commencement  of  the  illness,  while  further  on  the  temperature 
may  be  normal  or  nearly  so.  I  have  attended  a  number  of 
cases  in  which  the  temperature  remained  normal  throughout, 
and  again,  as  von  Niemeyer  points  out,  during  the  intervals 
of  the  shiverings  the  patient  may  experience  a  s'ensation  of 
burning  heat,  without  any  indication  from  the  thermometer 
of  an  actual  increase  of  temperature. 

The  laryngoscope  can  very  rarely  be  used  with  young 
children,  but  the  stethoscope  gives  equally  valuable  results. 
At  the  commencement  of  the  disease  sibilant  rales  are  heard 
all  over  the  tracheal  region,  with  increased  vocal  resonance. 
When  secretion  takes  place,  large  mucous  rales  replace  the 
sibilant  ones,  and  when  the  tracheal  mucous  membrane  is 
swollen  at  some  particular  point  a  well-marked,  sonorous 
rhoncus  is  heard. 

Postmortem  examinations,  as  well- as  examinations  with 
the  laryngoscope  during  life,  show  that  in  this  disease  the 
lining  membrane  of   the   trachea    is    of   an    intense    scarlet 


300  ri<\(  niiris. 

redness,  deepening  into  purple  in  very  severe  cases.  The 
entire  membrane  is  made  up  of  a  congeries  of  minute  florid 
blood-vessels,  so  closely  packed  together  as  to  give  the 
characteristic  scarlet  hue.  At  the  same  time,  the  follicles 
are  enlarged  and  very  prominent,  appearing  like  minute  red 
points  projecting  from  the  inflamed  surface,  which  has  a 
kind  of  glazed  appearance.  These  follicles  form  the  source 
of  the  thick  and  ropy  mucus  which  is  coughed  up.  Ulcers 
are  not  common,  and  softening  is  rarely  or  never  present, 
either  in  this  disease  or  in  laryngitis.  Prosser  James  points 
out  that  when  infiltration  takes  place  it  is  more  apt  to  be 
fibrinous  than  serous.  In  chronic  tracheitis  the  redness  is 
less  than  in  the  acute  form,  and  the  vessels  are  often 
varicose  ;  the  mucous  membrane  is  often  hypertrophied, 
indurated  and  ulcerated. 

The  diagnosis  is  comparatively  easy.  There  is,  of  course, 
nothing  characteristic  in  the  fever  which  precedes  the  attack, 
for  that  is  merely  the  fever  common  to  all  local  inflammations. 
More  characteristic  are  the  burning,  stinging  pain,  with  its 
peculiar  anatomical  seat,  the  clear  and  ringing  cough,  with 
the  gurgling  of  mucus  in  the  windpipe,  and  in  severe  cases, 
the  dysphagia,  with  constriction  and  swelling. 

The  prognosis  in  catarrhal  or  sthenic  tracheitis  is  almost 
uniformly  favorable — differing  widely  in  this  respect  from 
laryngitis  or  brochitis.  The  principal  danger  is  the 
disposition  to  become  chronic  and  to  extend  to  the  bronchial 
tubes.  Still,  one  can  easily  conceive  that  there  would  be 
danger  if  a  young  infant  of  feeble  vitality  should  be  attacked 
with  catarrhal  tracheitis  with  a  very  copious  secretion  of 
mucus. 

The  room  in  which  the  patient  sleeps  should  be  nearly  of 
the  same  temperature  as  that  which  he  occupies  during  the 
day,  and  while  draughts  should  be  carefully  avoided, 
ventilation  should  be  as  carefully  maintained.  Warm 
moisture  should  be  added  to  the  atmosphere  of  the  room  in 
severe  cases,  and  great  care  should  be  taken  when  the 
patient  first  goes  into  the  open  air  after  recovery. 


TRACHEITIS'.  301 

Aconite  must  ever  be  the  first  remedy  thought  of  if  the 
physician  is  called  at  or  near  the  commencement  of  the 
illness.  It  is  adapted  to  the  etiology  of  the  disease,  for 
exposure  to  wet  and  cold  is  by  far  the  most  influential 
factor  in  its  causation.  If,  however,  the  physician  is  not 
called  during  the  first  forty-eight  hours,  Aconite  is  of  little 
or  no  avail  and  another  remedy  must  be  selected  according 
to  the  symptoms  present.  I  have  generally  used  Aconite 
from  the  mother-tincture  to  the  3d  decimal  trituration,  and 
see  no  necessity  for  going  higher  in  the  scale. 

In  the  catarrhal  form  no  remedy  equals  Sanguinaria, 
which,  moreover,  is  able  to  prevent  extension  to  the  bron- 
chial tubes,  and  also  the  recurrence  of  the  disease.  I  am 
thoroughly  convinced  that  when  patients  subject  to  croup 
or  tracheitis  are  treated  with  Sanguinaria,  they  lose  the 
predisposition  to  these  diseases.  Usually  after  a  few  prelim- 
inary doses  of  the  inevitable  Aconite,  I  give  Sanguinaria 
with  unvarying  success,  though  exceptional  cases  occur 
which  demand  other  remedies. 

Tartar  emetic  is  indicated  when  the  cough  is  very  frequent 
with  audible  rattling  of  mucus  in  the  windpipe  and  bronchi 
— the  mucus  is  tough,  white  and  copious.  The  larynx  is 
little  affected,  but  inclination  to  vomit  is  often  present. 
Threatening  paralysis  of  the  lungs  is  best  met  by  this 
remedy.  Tartar  emetic  acts  best  in  repeated  doses  of  the 
3d  or  4th  decimal  trituration. 

Mercurius  solubulis  is  an  excellent  remedy  in  catarrhal 
tracheitis ;  dry,  distressing  cough,  usually  recurring  at  night 
and  racking  the  entire  frame.  The  patient  is  sensitive  to 
cold,  chills  alternate  with  paroxyms  of  burning  heat,  and  the 
tracheitis  is  merely  the  most  prominent  part  of  a  general 
catarrhal  fever.  I  have  generally  given  this  remedy  in 
powders  of  the  6th  decimal  trituration,  dry  on  the  tongue. 

Spongia  is  indicated  when  the  cough  is  hoarse,  ringing 
and  hollow,  with  labored  and  wheezing  breathing.  The 
cough  is  distinctly  paroxysmal,  and  is  usually  without  expec- 
toration. Spongia  acts  in  all  dilutions  ;  I  usually  give  the 
6th  decimal  trituration. 


302  TRACHEITIS. 

Hepar  is  very  like  Spongia,  differing  from  it  in  the  large 

quantity  of  mucus  present.  The  cough  is  hoarse  and  barking, 
and  a  suffocative  feeling  is  almost  constantly  present. 
Hepar  acts  well  in  all  dilutions;  I  prefer  the  [2th  decimal 
trituration. 

Sulphur  is  frequently  indicated  towards  the  close  of  the 
disease  when  a  dry  cough  remains  with  feelingof  constriction 
in  the  chest,  worse  after  eating  or  during  deep  inspiration. 
The  30th  is  the  most  suitable  preparation. 

Aphorisms. 

1.  Tracheitis  exists  as  a  separate  disease,  though,  as  it 
often  co-exists  with  laryngitis  and  bronchitis,  its  existence 
has  been  questioned. 

2.  The  leading  symptoms  are  a  burning,  stinging  pain  in 
the  windpipe,  with  dysphagia  and  local  swelling.  These 
symptoms  are  preceded  ,by  fever  and  accompanied  by  dry, 
spasmodic  cough  and  ringing  voice. 

3.  The  prognosis  is  almost  uniformly  favorable,  but  the 
disposition  to  become  chronic  and  to  extend  to  the  bronchi 
should  be  carefully  guarded  against. 

4.  The  homoeopathic  remedies  are  Aconite,  Sanguinaria, 
Tartar  emetic,  Mercurius  solubulis,  Spongia,  Hepar  and 
Sulphur.  Sanguinaria  removes  the  predisposition  to  the 
disease. 


INDEX 


Aconite,  in  acute  coryza, 
in  purulent  coryza, 
in  spasm  of  the  glottis, 
in  acute  catarrhal  laryngitis, 
in  acute  cedametous  laryngitis, 
in  spasmodic  croup, 
in  pseudo-membranous  croup, 
in  diphtheritic  croup, 
Ailanthus,  in  chronic  coryza, 
Allium  cepa,  in  acute  coryza, 
Alumina,  in  chronic  coryza, 
in  scarlatinal  croup, 
in  tracheitis, 
Ammonium  carbonicum,  in  acute  coryza, 
Ammonium  causticum,  in  diphtheritic  croup 
Antimonium  crudum,  in  chronic  coryza, 
Apis  mellifica,  in  purulent  coryza, 

in  acute  cedematous  laryngitis, 
in  diphtheritic  croup, 
Argentum  nitricum,  in  purulent  coryza, 
in  chronic  coyrza, 
in  acute  catarrhal  laryngitis, 
Asafcetida,  in  chronic  coryza, 
Arsenicum  album,  in  acute  coryza, 

in  spasm  of  ^he  glottis, 
in  acute  catarrhal  laryngitis, 
in  acute  cedematous  laryngitis, 
Arsenicum  iodatum,  in  chronic  coryza, 
Arum  triphyllum,  in  acute  coryza, 
Aurum  metallicum,  in  chronic  coryza, 
Baryta  carbonica,  in  chronic  coryza,        .     . 
Belladonna,  in  acute  coryza, 
in  purulent  coryza, 
in  spasm  of  the  glottis, 
in  acute  catarrhal  laryngitis,      . 
Berberis,  in  chronic  coryza, 
Bouchut,  on  the  use  of  canuk-e  in  acute  coryza, 
Bromine,  in  spasm  of  the  glottis, 

in  pseudo-membranous  croup, 
in  diphtheritic  croup, 


PAGE 

29.  37 

49 

89 

127 

147 

164 

218 

286 

63 

34 

58 

292 

301 

36 

281 

62 

49 

143 

282 

47 
57 
131 
63 
32 

91 
130 
148 

62 

36 
57 
59 
33 

49 

92 

129 

63 

37 

108 

225 

279 


I  n :  I )  E  X  . 

lia,  in  acute  con    a, 

36 

in  acute  catarrhal  laryngitis, 

130 

in  p                mbranous  croup, 

232 

rea  carbonica,  in  chronic  coryza, 

55 

<  '.imphor,  in  acute  CO 

30 

Carbo  vegetabilis,  in  acute  coryza, 

36 

Chamomilla,  in  acute  coryza, 

33 

in  spasm  of  the  glottis, 

109 

Chlorine,  in  spasm  of  the  glottis. 

99 

cute,           ..... 

25 

etiology  of,              ...              . 

26 

nature  of,          . 

27 

symptomatology  of, 

27 

progress  of, 

29 

therapeutics  of,      . 

29 

general  management  of,           . 

37 

aphorisms  of,          . 

38 

Coryza,  chronic,         ..... 

5i 

varieties  of,             ...             . 

51 

etiology  of, 

5i 

symptomatology  of, 

52 

thermometry  of,            ...             . 

53 

diagnosis  of,           . 

53 

prognosis  of,                  .... 

54 

general  management  of ,     . 

54 

therapeutics  of,             ...             . 

54 

aphorisms  of, 

63 

Coryza,  purulent,      ..... 

39 

etiology  of,              ...             . 

41 

symptomatology  of,     . 

42 

thermometry  of, 

44 

pathological  anatomy  of,           . 

44 

prognosis  of,           . 

46 

general  management  of,           . 

46 

therapeutics  of,       . 

47 

aphorisms  of,                 .... 

50 

Corallia  rubra,  in  spasm  of  the  glott's, 

10S 

(.roup,  diphtheritic,                .... 

235 

history  of,                  .... 

236 

etiologv  of,         . 

241 

symptomatology  of,              ... 

244 

pathological  anatomy  of, 

249 

pr<  gnosis  of,             ... 

266 

tracheotomy  in,                .... 

268 

general  treatment  <.f. 

274 

therapeutii                      .... 

275 

aphorisms  of,            .              .              .             . 

286 

INDEX. 

305 

Croup,  pseudo-membranous, 

171 

definition  of,              .... 

173 

etiology  of,         . 

177 

symptomatology  of,               .... 

190 

progress  of,        . 

199 

thermometry  of, 

2oi 

physical  diagnosis  of,      . 

202 

essential  nature  of,                .... 

204 

pathological  anatomy  of, 

206 

diagnosis  of,             ....             • 

210 

prognosis  of,       . 

214 

tracheotomy  in,         . 

2 1 6 

therapeutics  of,               .             .             . 

21S 

aphorisms  of,            .... 

233 

Croup,  scarlatinal,     ..... 

2S8 

definition  of, 

2S8 

etiology  of,         . 

289 

symptomatology  of,               .... 

289 

pathological  anatomy  of, 

290 

diagnosis  of,              .... 

291 

prognosis  of,      . 

292 

therapeutics  of,         . 

292 

aphorisms  of,      . 

293 

Croup,  spasmodic,           ..... 

154 

etiology  of ,         . 

157 

physical  diagnosis  of,            ... 

162 

pathological  anatomy  of, 

162 

diagnosis  of,              ...              .             . 

163 

prognosis  of,       . 

163 

therapeutics  of,         . 

163 

general  treatment  of,     . 

168 

aphorisms  of,            ...             . 

170 

Cyclamen,  in  acute  coryza, 

36 

in  chronic  coryza,              .... 

62 

Cuprum  metallicum,  in  spasm  of  the  glottis, 

106 

Dulcamara,  in  acute  coryza,        .... 

36 

Dunham,  Dr.  Carroll,  on  chlorine  in  s4  asm  of  the  glotti 

;,              .                 100 

Euphrasia,  in  acute  coryza,         .... 

34 

Gelsemium,  in  spasm  of  the  glottis. 

95 

Graphites,  in  chronic  coryza,       .... 

60 

Hayward,  on  the  local  use  of  Aconite  in  c>cute  coryza, 

37 

Hepar  sulphuris,  in  acute  coryza, 

32 

in  chronic  coryza, 

62 

in  acute  catarrhal  laryngitis, 

12S 

in  spasmodic  croup, 

166 

in  tracheitis,           .... 

302 

\o6 


i  n  r  >  e  x  . 


Hering,  Constantine,  on  the  etiology  of  acute  coryza, 
Hippocrates,  on  the  general  treatment  of  a< 
rlydrastic  canadensis,  in  chronic  co 
Hyosciaimis,  in  acute  catarrhal  laryngitis 

Ipecacuanha,  in  acute  coi 

in  spasm  of  the  glottis, 
in  acute  catarrhal  laryngitis, 
Ignatia,  in  spasm  of  the  glot:is. 
Iodine,  in  chronic  coryza, 
in  spasm  of  the  glottis, 
in  acute  cedematous  laryngitis, 
in  pseudo-membranous  croup, 
in  diphtheritic  croup. 
Kali  bichromicum,  in  chronic  coryza,     . 

in  pseudo-membranous  croup, 
in  diphtheritic  croup, 
Kali  carbonicum,  in  chronic  coryza, 
Kali  hydrodicum,  in  chronic  coryza, 
Lachesis,  in  chronic  coryza, 
in  spasm  of  the  glottis, 
in  acute  catarrhal  laryngitis, 
in  acute  cedematous  laryngitis, 
in  diphtheritic  croup, 
Laryngitis,  acute  catarrhal, 
nature  of,        .  , 

etiology  of, 
symptomatology  of, 
thermometry  of, 
pathological  anatomy  of, 
aphorisms  of, 
prognosis  of, 
general  treatment  of, 
therapeutics  of, 
aphorisms  of, 
Laryngitis,  acute  cedematous, 
nature  of, 
varieties  of, 
symptomatology  of, 
progress  of, 

pathological  anatomy  of, 
diagnosis  of, 
prognosis  of, 
therapeutics  of, 
operative  interference  in, 
aphorisms  of,  .  , 

Laurocerasus,  in  spasm  of  the  glottis 


33 
37 
62 

L3i 
36 
94 

131 

ro6 

62 

98 

148 

221 

27S 

56 

227 

275 

60 

6l 

60 

107 

130 

I4S 

284 

Il6 

"7 
Il8 
Il8 
121 
122 
123 
124 
124 

125 
127 

132 
132 

133 
I36 

137 
139 
I40 
142 

143 

I49 

152 
109 


INDEX. 


307 


Lobelia,  in' spasmodic  croup, 

Lycopodium,  in  chronic  coryza, 

Meigs,  Dr.  Chas.  D.,  on  the  flannel  cap  in  acute  coryza 

Mercurius  iodatus,  in  chronic  coryza, 

Mercurius  solubulis,  in  acute  coryza, 

in  acute  catarrhal  laryngitis, 
in  tracheitis, 
Moschus,  in  spasm  of  the  glottis, 
Nitric  acid,  in  purulent  coryza, 

in  chronic  coryza, 
Nux  Vomica,  in  acute  coryza, 

in  spasm  of  the  glottis, 
in  acute  catarrhal  laryngitis, 
Opium,  in  spasm  of  the  glottis, 
Phosphorus,  in  acute  catarrhal  laryngitis, 
in  spasmodic  croup, 
in  pseudo-membranous  croup, 
Plumbum,  in  spasm  of  the  glottis, 
Pulsatilla,  in  acute  coryza, 

in  spasm  of  the  glottis, 
in  acute  catarrhal  laryngitis, 
Sanguinaria  canadensis,  in  acute  coryza, 
in  spasm  of  the  glottis, 
in  acute  catarrhal  laryngitis, 
in  acute  oedematous  laryngitis 
in  pseudo-membranous  croup, 
in  diphtheritic  croup, 
in  scarlatinal  croup, 
in  tracheitis, 
Sambucus,  in  acute  coryza, 

in  spasm  of  the  glottis, 
in  acute  catarrhal  laryngitis, 
Scald  throat, 
Sepia,  in  chronic  coryza, 
Silicia,  in  chronic  coryza, 
Spasm  of  the  glottis, 
nature  of, 
etiology  of,         . 
symptomatology  of, 
mode  of  death  in, 
therapeutics  of, 
general  treatment  of 
chloroform  in, 
tracheotomy  in, 
lancing  of  the  gums  in, 
diet  in, 
aphorisms  of, 


168 
59 
37 
62 

3i 

130 

301 

88 

48 

61 

30 

108 

131 

108 
130 
167 
232 

107 

35 

108 

131 

36 

90 

127 

145 

22S 

286 

292 

301 

36 

87 

131 

138 

58 

55 

64 

65 
68 

77 
87 
87 
no 
in 
in 
112 
112 
114 


3o8 


i  n  d  i :  x 


Spongia,  in  spasm  of  the  glottis, 
in  acute  catarrhal  laryngitis, 
in  acute  (Edematous  laryngitis, 
in  spasmodic  croup, 
in  diphtheritic  croup, 
in  tracheitis, 
Stannum  metallicum,  in  chronic  coryza, 
Sulphur,  in  chronic  coryza, 

in  spasm  of  the  glottis, 
in  tracheitis, 
Tartar  emetic,  in  acute  catarrhal  laryngitis, 
in  pseudo-membranous  croup, 
in  diphtheritic  croup, 
in  tracheitis, 
Tracheitis,  .... 

definition  of,        . 
etiology  of, 
symptomatology  of, 
thermometry  of, 
pathological  anatomy  of, 
diagnosis  of, 
prognosis  of, 
general  treatment  of, 
therapeutics  of, 
aphorisms  of, 
Veratrum  album,  in  spasm  of  the  g  ottis, 
Williams,  Dr.  C.  J.   B.,  on  the  thirst  cure  in  acute 
Zincum  metallicum,  in  spasm  of  the  glottis, 


coryza, 


109 
128 

148 

165 
286 
301 
62 
54 
109 
302 
129 
231 
285 
3or 
294 

295 
296 
296 
299 
299 
299 
300 
300 
301 
302 
109 

37 
108 


RETURN      BIOLOGY  LIBRARY                        8  2  4  7 

TO— ►      3503  Life  Sciences  Bldg.     642-2531 

LOAN  PERIOD  1 

2 

5 

4        1 -MONTH-  -IV  .ji^UbKMrn 

ALL  BOOKS  MAY  BE  RECALLED  AFTER  7  DAYS 
Renewed  books  are  subject  to  immediate  recall 

DUE  AS  STAMPED  BELOW 

NED 

! '°  19fl 

s 

'  IBRAR' 

f 

UNIVERSITY  OF  CALIFORNIA,  BERKELEY 
FORM  NO.  DD4  BERKELEY,  CA  94720 

©s 


U.C.BERKELEY  LIBRARIES 


CDSlTimET 


